REPORT DIGEST ANDREW MCFARLAND MENTAL HEALTH CENTER LIMITED SCOPE COMPLIANCE
EXAMINATION For the Two Years Ended: June 30, 2007 Summary of Findings: Total this report 3 Total last report 2 Repeated from last report 0 Release Date: June 12, 2008
State of Illinois Office of the Auditor General WILLIAM G. HOLLAND AUDITOR GENERAL To obtain a copy of the
Report contact: Office of the Auditor
General Iles Park Plaza 740 E. Ash Street Springfield, IL 62703 (217) 782-6046 or TTY (888) 261-2887 This Report Digest is also
available on the worldwide web at http://www.auditor.illinois.gov |
SYNOPSIS ¨ The Center did not ensure adequate procedures exist for disposal of documents containing personal or confidential information. ¨
The Center did
not maintain adequate documentation of the timely evaluation of residents for
mental retardation.
{Expenditures and Activity Measures are summarized on the reverse page.} |
ANDREW MCFARLAND MENTAL
HEALTH CENTER
LIMITED SCOPE
COMPLIANCE EXAMINATION
EXPENDITURE STATISTICS |
FY 2007 |
FY 2006 |
FY 2005 |
||||
·
Total Expenditures (All Appropriated Funds)................................................. |
$18,470,170 |
$16,974,852 |
$16,404,075 |
||||
OPERATIONS TOTAL......................... |
$18,458,770 |
$16,963,452 |
$16,392,675 |
||||
% of Total
Expenditures..................... |
99.9% |
99.9% |
99.9% |
||||
Personal
Services............................... |
$13,168,298 |
$12,297,736 |
$11,387,575 |
||||
%
of Operations Expenditures......... |
71.3% |
72.5% |
69.5% |
||||
Average
No. of Employees............. |
229 |
221 |
216 |
||||
Average
Salary Per Employee........ |
$57,503 |
$55,645 |
$52,720 |
||||
Other
Payroll Costs (FICA,
Retirement)..................................... |
$2,466,210 |
$1,955,084 |
$2,595,973 |
||||
%
of Operations Expenditures......... |
13.4% |
11.5% |
15.8% |
||||
Commodities ………………………. |
$392,840 |
$378,250 |
$339,485 |
||||
% of Operations Expenditures.......... |
2.1% |
2.2% |
2.1% |
||||
Contractual
Services........................... |
$2,012,576 |
$1,883,160 |
$1,701,106 |
||||
%
of Operations Expenditures......... |
10.9% |
11.1% |
10.4% |
||||
All
Other Items................................... |
$418,846 |
$449,222 |
$368,536 |
||||
%
of Operations Expenditures......... |
2.3% |
2.7% |
2.2% |
||||
|
|
|
|
||||
GRANTS
TOTAL.................................. |
$11,400 |
$11,400 |
$11,400 |
||||
% of Total Expenditures..................... |
0.1% |
0.1% |
0.1% |
||||
·
Cost of Property and Equipment........ |
22,049,975 |
$22,106,859 |
$22,158,443 |
||||
|
|
|
|
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SELECTED ACTIVITY MEASURES (Not examined) |
FY 2007 |
FY 2006 |
FY 2005 |
||||
·
Average Number of Residents......................................... |
115 |
115 |
112 |
||||
·
Ratio of Employees to
Residents...................................... |
1.99/1 |
1.92/1 |
1.93/1 |
||||
·
Paid Overtime Hours
and Earned Compensatory Hours |
18,360 |
23,235 |
19,307 |
||||
·
Value of Paid Overtime
Hours and Earned Compensatory Hours............................................................................ |
$605,712 |
$770,011 |
$601,268 |
||||
·
Cost Per Year Per Resident............................................. *The Department had not calculated this statistic at
the close of fieldwork. |
* |
$185,579 |
$188,926 |
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HOSPITAL ADMINISTRATOR(S) |
|||||||
During
Period: Scott Viniard (1/16/04 –
9/15/07), Karen Schweighart
(beginning 9/16/07) |
|||||||
Currently: Karen Schweighart |
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Confidential
information in recycling containers
Procedures not
adequate or always enforced
Residents’ files did not contain an evaluation notice Could not determine if notification was given to resident within 24
hours
Phone number and
address of the Legal Advocacy Service not included |
FINDINGS, CONCLUSIONS ANDRECOMMENDATIONS IMPROPER DISPOSAL OF CONFIDENTIAL INFORMATION The Center did not ensure adequate procedures exist for disposal of documents containing personal or confidential information. During a visit at the Center we found confidential information was not always placed in the secured bins. For example, we found the following information within unlocked recycling containers: · Resident psychiatric evaluation; · Hand-written note identifying resident name and arrival date; · Several documents (Forensic Unit Patient Transports, Workshop Request forms, and email correspondence), identifying resident name, including email disclosing patient’s primary diagnosis; · Sensitive information that identified applicant names, addresses, telephone numbers and education/employment histories. Although written procedures for disposing of confidential information existed, the procedures were not adequate or always enforced. In addition, there was no formal security awareness program for providing Center employees with guidelines as to the type of information employees were required to shred. (Finding 1, pages 10-11) We recommended the Center perform a risk assessment to assure personal or confidential information is adequately safeguarded and appropriately disposed of when no longer needed. Center officials agreed with the finding and stated the Quality Manager will assess and ensure the adequacy of the Center’s HIPAA procedures and continue to ensure diligent training of employees. EVALUATIONS
AND NOTIFICATIONS WERE NOT ADEQUATELY DOCUMENTED The Center did not maintain
documentation of the timely evaluation of residents for mental retardation. In addition,
the notices given to residents lacked the phone number and address of the
Legal Advocacy Service of the Guardianship and Advocacy Commission (Commission).
·
Six of 25 (24%) files tested did not contain an evaluation notice; therefore, we could not determine if
the resident was evaluated as being mildly or moderately mentally retarded
within 14 days after admission and notified within 24 hours of the evaluation.
·
Fifteen of 25
(60%) files tested did not contain documentation of the date the notification
was given to the resident, so we could not determine if the notification was
given within 24 hours of the evaluation.
·
Fifteen of 25
(60%) files contained notifications that did not include the phone number and
address of the Legal Advocacy Service of the Commission. (Finding 2, pages 12-13) We recommended the Center complete
and document the evaluations for mental retardation within 14 days of the
resident’s admission. We also
recommended the Center include all mandated information on the notification
and ensure the individual and all applicable parties are notified within 24
hours of the evaluation. Center officials agreed with the finding and stated the 24 hour form present on all charts did not meet the requirements, and the Center did complete the assessments. The Center also stated the form was modified to include the required information within the specified timeframe. OTHER FINDING The remaining finding is reportedly being given attention by the Center. We will review the Center’s progress toward implementation of our recommendations in our next examination. AUDITORS’ OPINION
We conducted a limited scope compliance examination of the Center as required by the Illinois State Auditing Act. Financial statements for the entire Department of Human Services will be presented in the Department’s audit report. ______________________________________ WILLIAM G. HOLLAND, Auditor General WGH:PH:pp AUDITORS ASSIGNED
The compliance examination was conducted
by the Office of the Auditor General’s staff. |