by Marijo Rymer, Executive Director at The Arc of Colorado
On Dec. 9, the Legislative Audit Committee received the performance audit conducted by the State Auditor of the three Regional Centers providing services for people with IDD. As of March, 2013, the centers located in Grand Junction, Pueblo and Wheat Ridge served a total of 302 clients in three programs:
• 242 clients in long term habilitation –for people with high medical and/or high behavioral needs unlikely to be stabilized within 90 days. 70% of these clients have been residents at a Regional Center for 10 or more years.
• 40 clients in intensive treatment –for people with criminal convictions, a history of sexual offense, or those who pose a serious safety risk. The goal of intensive treatment is to prepare clients for community placement within 3 years of admission.
• 20 clients receiving short-term treatment—emergency placement for people who have high medical or behavioral needs. The goal of the program is to stabilize the person through specialized services within 90 days and to prepare the individual for community placement.
All clients at the Regional Centers must have a rights restriction imposed by a District Court based on the statutory definition of legal disability.
• The Wheat Ridge Regional Center operates solely as an ICF/IDD (Intermediate Care Facility for persons with Intellectual/Developmental Disabilities.) A range of services including 24 hour supervision, intensive treatment for those who have exhibited problematic sexual or violent behavior, acute health care, and rehabilitative services. ICF/IDD services are funded through the state Medicaid plan.
• The Grand Junction Regional Center operates both as an ICF/IDD and with group homes funded under the HCBS Medicaid waivers.
• The Pueblo Regional Center only operates group homes funded under the HCBS Medicaid waivers.
The total population of the Regional Centers decreased by 24% from FYs ‘03 (391) to ‘12 (296) but the average daily cost increased by 15% ($510 in ’03 and $584 in ’12) adjusted for inflation.
Key findings include:
• The average daily cost in FY 2012 to serve clients ranged from a high of $845.76 for ICF/IDD clients at Grand Junction to $470.56 for HCBS waiver clients at Pueblo. Cost variances are attributable to the per client expense of personal services and in some cases the credentialing requirements for staff which may result in higher labor costs; GJ requires that all direct care staff be licensed psychiatric technicians.
• Facility costs at GJ (average daily expense for ICF/IDD of $82.86 and $36.11 for HCBS Waivers) are higher than at the other two sites ($18.37—WR and $27.55—Pueblo) partly because of the number of unused buildings on the campus that require upkeep and maintenance.
• CO statute requires that CO Medicaid reimburse the Regional Centers for actual costs for clients covered under a HCBS Medicaid waiver. However, costs do not align with reimbursements. In FY ’12, Medicaid reimbursements exceeded costs by $1.3 million
• HCPF mistakenly made Medicaid payments of $2,955 to CCBs for services that should not have been billed for clients who had been transitioned from community placement to the RC.
• RCs did not maintain clear or consistent data regarding the rationale for classifying clients as ready to transition to the community.
• RCs have not met goals for the time required to transition clients to community based services. Of 57 clients determined to be ready for transition, delays ranged from 32 to 441 days. The audit identified errors for about 65% of clients in the transition process.
Audit recommendations: The audit identified 11 major recommendations. The Department of Human Services and HCPF agreed with all and indicated potential implementation dates between Dec. 2013 and July, 2014.
• Improve monitoring of costs and variances using consistent categories among RCs
• Ensure that ICF/IDD resources are fully reimbursed for actual costs by CO Medicaid and request retrospective reimbursement for expenses that were inadequately billed.
• Ensure that RC cost reports accurately report the number of resident days.
• Implement a review and approval process for Medicaid reimbursement to compare calculations made by the contracted accounting firm with actual costs.
• Ensure that HCBS waiver rates reflect actual costs.
• Provide needed training to CCBs to ensure that Medicaid is not billed for services provided during a residential stay at a RC.
• The state must pay the provider fee for ICF/IDDs and collect same from the state’s only private ICF/IDD.
• Verify that DHS collects the provider service fee from each provider billed.
• RCs must conduct consistent assessments of readiness to transition to community based services.
• Improve transition processes to make sure that barriers to transition are correctly and consistently identified.
• Expand and improve DHS methods for tracking, analyzing, and reporting RC performance in transitioning people from the state institution to private providers.