REPORT DIGEST

CHICAGO - READ
MENTAL HEALTH CENTER

COMPLIANCE AUDIT
For the Two Years Ended:
June 30, 1997

Summary of Findings:

Release Date:
March 12, 1998

State of Illinois
Office of the Auditor General

WILLIAM G. HOLLAND
AUDITOR GENERAL

Iles Park Plaza
740 E. Ash Street
Springfield, IL 62703
(217) 782-6046

SYNOPSIS

• The Center did not have current performance evaluations in 9 of 35 personnel files reviewed.

• The Center did not perform required dental exams for all recipients who were at the Center for more than 18 months.

• The Center did not perform or properly document all required medication reviews for recipients receiving psychotropic medications.

{Expenditures and Activity Measures are summarized on the reverse page.}

FY 1997

FY 1996

FY 1995

• Total Expenditures (All Appropriated Funds)
  
  OPERATIONS TOTAL
  % of Total Expenditures
  Personal Services
  % of Operations Expenditures
  Average No. of Employees
  Average Salary Per Employee
  
  Other Payroll Costs (FICA, Retirement)
  % of Operations Expenditures
  
  Contractual Services
  % of Operations Expenditures
  
  Commodities
  % of Operations Expenditures
  
  All Other Items
  
  % of Operations Expenditures
  
  GRANTS TOTAL
  % of Total Expenditures
  
  
  
• Cost of Property and Equipment
  
• Cost of Inventory on Hand

$31,651,319


$31,651,319
100%
$25,653,411
81.0%
578
$44,383

$2,992,736
9.5%

$1,867,665
5.9%

$749,859
2.4%

$387,648

1.2%

$0
0%


$17,941,295
$409,573

$31,321,141


$31,321,141
100%
$25,130,952
80.2%
589
$42,667

$2,884,926
9.2%

$2,056,989
6.6%

$839,670
2.7%

$408,604

1.3%

$0
0%


$25,258,740
$438,911

$30,367,277


$30,367,277
100%
$24,583,929
80.9%
590
$41,668

$2,606,937
8.6%

$2,090,260
6.9%

$704,441
2.3%

$380,903

1.3%

$0
0%


$55,617,810
$349,903

FY 1997

FY 1996

FY 1995

• Average Number of Residents
  
  
• Ratio of Employees to Residents
  
  
• Cost Per Year Per Resident
  
  
• Department's progress in reducing employees' injuries (Workers' Compensation Claims)
  

222

2.6/1

$173,689

181

245

2.4/1

$157,502

206

286

2.06/1

$136,606

Not Available

During Audit Period: Thomas Simpatico, M.D./ James Brunner, M.D.

Currently: Thomas Simpatico, M.D./ James Brunner, M.D.

9 of 35 employee files did not have current performance evaluations.

3 of 8 recipients did not receive required dental exams.

Medication reviews were not conducted or properly documented for 15 of 49 recipients.

FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS

LACK OF PERFORMANCE EVALUATIONS

The Center did not complete employee performance evaluations in a timely manner. Nine of 35 employee files examined did not contain evidence of current performance evaluations. Department policies require annual evaluations for Center personnel. While the Center had procedures to ensure evaluations were performed and placed in personnel files, these procedures were not consistently followed. (Finding 1, Page 13)

We recommended the Center comply with the Policy and Procedure Directives and adhere to Center procedures to ensure the Center completes performance evaluations in a timely manner and maintains evaluations in personnel files.

Center officials accepted our recommendation.

LACK OF DENTAL EXAMINATIONS

The Center did not complete dental examinations for recipients who were at the Center for over 18 months. The Department of Mental Health and Developmental Disabilities Act (20 ILCS 1705/7) requires dental examinations for recipients at least once every 18 months. Three of eight recipients, whose files were reviewed, did not receive the required dental examinations. Center officials stated this condition occurred because it did not have procedures to identify and track recipients in need of dental exams. (Finding 2, Page 14)

We recommended the Center comply with the Mental Health and Developmental Disabilities Act and establish new procedures to identify recipients who by statute must have dental exams.

Center officials accepted our recommendation
.

LACK OF MEDICATION REVIEWS

The Center did not perform or properly document medication reviews. This finding has been repeated from our Fiscal Year 1995 audit. Audit tests disclosed the Center did not conduct medication treatment reviews for 15 of 49 recipients whose files were reviewed. The Mental Health and Developmental Disabilities Code (405 ILCS 5/2-107.2) requires a treatment review panel, established by the facility director, to periodically assess the medication treatment of those individuals receiving psychotropic medication. The Code requires an initial review after three months and every six months thereafter. Center personnel indicated that they were unable to locate documentation to show the reviews were performed. These reviews and related documentation are important to the quality of care provided by the Center. (Finding 3, Page 15)

We recommended the Center comply with the Mental Health and Developmental Disabilities Code. Center officials accepted our recommendation and stated the recommendation has been implemented. (For the previous Center response, see Digest Footnote 1.)

Mr. Jim Donkin, Department of Human Services' Chief Internal Auditor provided responses to our recommendations. All responses were received in December 1997.

OTHER ISSUES

In September 1993 the Center lost its accreditation by the Joint Commission for Accreditation of Health Care Organizations (JCAHO) due to physical plant and safety issues. In September 1997, the JCAHO conducted a survey resulting in provisional accreditation pending a final survey tentatively scheduled for April 1998.

In addition, a September 1997 survey by the United States Department of Health and Human Services revealed no deficiencies and the Center received its Medicare recertification.

AUDITORS' OPINION

Our auditors report that the financial statements of the Center's Locally Held Funds at June 30, 1997 and 1996 are fairly presented.

____________________________________
WILLIAM G. HOLLAND, Auditor General

WGH:JAW:ak

SPECIAL ASSISTANT AUDITORS

Our special assistant auditors were Nykiel, Carlin, Lemna & Company.

DIGEST FOOTNOTE

#3 LACK OF MEDICATION REVIEWS - Previous Agency Response

1995: Accepted. The timeframes for the medication review teams have been adjusted to be in compliance with the statutory mandate (i.e., initial reviews after 90 days and follow-up reviews every 180 days)

.