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

For The Two Years Ended June 30, 2007

 

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

 

 

 

 

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

HOSPITAL ADMINISTRATOR(S)

      During Period:  Scott Viniard (1/16/04 – 9/15/07),   Karen Schweighart (beginning 9/16/07)

      Currently:          Karen Schweighart



 

 

 

 

 

 

 

 

 

 

 

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 AND

RECOMMENDATIONS

 

 

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.