Audit authorized by Resolution # 390-10

Scope of audit limited to Muscogee County Jail Clinic

Policies & Procedures

Payroll Issues & Overtime

Medical Records Review

Third-Party Provider Contract for Emergency Care

Budgetary Performance & Backlog of Unpaid Jail Clinic Invoices

POLICIES & PROCEDURES- ISSUE/CONCERN:

Does the Muscogee County Jail Clinic have current Policies and Procedures that are effective, reasonable, and adequate; and do they include elements of internal control that specify boundaries of quality performance, authority, conduct and elicit the necessary communication and notification between functional area to ensure the success of the clinical operation and adequacy and timeliness of healthcare services to inmates?

Few Policies & Procedures found to be in place

Clinic Service Administrator, Paul Morris working to re-develop Policies & Procedures, noting earlier ones were discarded during his absence

Most communication and directives to staff by word-of-mouth, without specificity of expected outcomes

Lack of definition as to skill level/training required to perform certain operational functions

POLICIES & PROCEDURES- RECOMMENDATIIONS:

Clinic management company (CHC) to develop Policies & Procedures complain with federal, state, and local requirements

Follow-up evaluation of Policies & Procedures by Auditor after development /Staff Training by CHC

POLICIES & PROCEDURES- MANAGEMENT RESPONSE:

CHC has been contracted to provide in-mate medical care and support, privatizing the clinic

CHC to develop, implement, & train staff on their Policies and Procedures that are used nationwide in their clinics, eliminating ambiguity on Policies and Procedures

PAYROLL RECORDS OVERTIME ISSUES:

Time reporting

Payroll calculation

Clinic staffing

Contract labor

Overtime expense

Payroll vs. budget

PAYROLL RECORDS/OVERTIME:

Payroll time recorded via electronic time clock with relatively few manual entries, except for one employee during payroll test period

Payroll calculations were verified to be correct based on the hours reported and current pay rates

Payroll was distributed by auditor to all payees, ensuring that the employees exist

Clinic staffing vacancies & absences frequently resulted in the use of staff overtime and contract labor usage to cover staffing needs

Overtime hours were excessive, with some employees overtime earnings representing a substantial portion of their total earnings

As a result of overtime & contract labor, the clinic payroll budget was routinely exceeded

If the Jail Clinic continues to employ staffing, management needs to pro-actively recruit more full-time and part-time staff, to avoid excessive overtime and employee burn-out

Efforts need to be made to improve scheduling so that overtime is not built into the work schedules of employees; overtime should only be used for unforeseen emergencies

PAYROLL RECORDS/OVERTIME- MANAGEMENT RESPONSE:
Privatizing the clinic will eliminate the need for employees having to work overtime

The privatizing process showed that the clinic was inadequately staffed, often leading to overtime

Salary is a fixed component of the contract with CHC

CHC will implement their nationwide policies & procedure for handling payroll

MEDICAL RECORDS REVIEW- ISSUES:

Alleged photocopied or falsified In-mate Intake Medical Records by one or more intake screeners

Inaccurate or incomplete medical records

Do medical records reflect medial examinations, medical testing, treatments and medications dispensed to in-mates?

MEDICAL RECORDS REVIEW-FINDINGS:

A statistical sample of medical record charts of in-mates revealed a consistent pattern on three of the six vital signs, taken and recorded by one of the medical intake screeners, consist with allegations; other medical intake screeners did not reveal such a pattern

Medical Record charts of inmates reflected a variety of medical exams, testing, treatments and medications dispensed, indicating reasonable documentation accuracy and completeness

The Medical Intake Screening Forms did not include the results of several PPD Tests and some height and weight measurements were unrecorded

Medical intake screeners consisted of persons employed as Medical Technicians, Licensed Practical Nurses and Registered Nurses

MEDICAL RECORDS REVIEW- RECOMMENDATINOS

t is recommended that medical intake screening be performed by licensed medical personnel with the requisite training needed to perform the process and properly record the results.

It is recommended that all intake screenings be reviewed by a Registered Nurse, Physician, or Physician Extender as soon as practicable after the screening occurs, to assess the need appropriate medical care.

MEDICAL RECORDS REVIEW – MANAGEMENT RESPONSE:

CHC’s Policies and Procedures will dictate personnel responsible for the intake medical screening process and the review process of said intake screenings.

THIRD PARTY PROVIDER CONTRACTS FOR EMERGENCY CARE – ISSUE:___________________________________________________________

Emergency Care for inmates/prisoners at the Jail and Prison is provided by The Medical Center-Midtown, partially funded by a $500,000 allowance from the Indigent Care Funding provided by the City to cover the cost of indigent care for the community. This allowance is part of the 30-year contract executed by the parties in 1992.

CONTRACTED EMERGENCY CARE – FINDINGS:

For a number of years, the emergency care allowance for inmates/prisoners of $500,000 was adequate. Due to rising costs and other factors, the billed charges have exceeded the allowance in recent years. Excess amounts are billed to the City at 50% of the hospital’s Chargemaster Rates

For the past three years, these additional amounts billed were: 2012- $822,063; 2011 - $623,412; 2010 - $852,944, according to a recent audit of the Indigent Care Contract

EMERGENC Y CARE CONTRACT – RECOMMENDATIONS:

It is recommended that care be provided at the Jail Clinic, whenever possible, to minimize the number of inmates taken to the hospital

It is recommended that the $500,000 emergency care allowance be apportioned between the Jail and the Prison, based on actual charges for the past 3 -5 years, and those amounts be included in their respective budgets, and future overages paid by the each entity, encouraging each to control their use of emergency care

CONTRACTED EMERGENCY CARE – MANAGEMENT RESPONSE:

Due to lack of specific case information, I am unable to address this issue regarding inmates sent out at the end of shift/upon arrival at jail. H.S.A. Morris has been successful at ensuring that the City only pays for services rendered. He investigates any abnormally high uses of emergency care. The Office will work with CHC to monitor inmates transfers to the ER

BUDGETARY PERFORMANCE – ISSUE:

How has the Jail Clinic performed in relation to its budget while providing care to inmates in its custody?

Does the Jail Clinic provide required inmate medical care to its inmates?

Is the care provided in a cost efficient manner?

BUDGETARY PERFORMANCE – FINDINGS:

Staying within the budget has been problematic for the clinic for a number of years, however, the problem has exacerbated in recent years. Additionally, emergency care cost overruns have been paid by the City in recent years, and are not reflected in the budgetary performance of the Jail Clinic. As stated earlier, overtime and contracted clinic staffing has contributed to the budget overage

The Jail Clinic provides a way array of services to its inmates, at the clinic site and by non-clinic providers. Medical, Dental, Vision, Medication Dispensing, Sick Call and Mental Health Services are performed within the Jail/Clinic. Emergency Care, Surgery, Dialysis, and Other Specialty Care is normally provided by outside providers

At the end of FY2013, a sizable backlog of unpaid Jail Clinic bills existed. It took an extended period of time to ascertain the dollar volume ($900,000+) and expense categories of these unrecorded liabilities. While the backlog may be due to extenuating circumstances, such is wrought with problems:

Management was unaware of their current budgetary performance, which can undermine credibility

FY2014 budget for the Jail Clinic without a reasonable projection of current year expenses to serve as a base for the upcoming year’s budget

It potentially delayed the completion of the external auditor’s field work, which may cause an increased cost for the audit

BUDGETARY PERFORMANCE – RECOMMENDATIONS:

Establish the necessary Policies and Procedures to provide a guideline of how decisions are to be made in the absence of direct supervision.

Require vendors to provide detailed invoices including item, quantity, size/dosage, and the unit price and extended price of each line item.

Perform regular inventories of items such as pharmaceuticals, which are highly marketable inside and outside of the facility.

Assign personnel to tasks for which they are fully qualified. State and Federal Regulations provide guidance in this area.

Prcess invoices, payroll and other cost items in a timely fashion, to allow management to review and act on budgetary and performance measures before such becomes unmanageable.

Employ a person, within the Sheriff’s Office, that is trained, skilled an experienced in the preparation of budgets, performing financial and operational analysis, and controlling expenses to budgeted levels.

Employ or contract management skilled in managing all critical aspects of jail clinic operations.

BUDGETARY PERFORMANCE – MANAGEMENT RESPONSE:

With the privatization of the clinic to CHC, their Policies and Procedures should ensure that we are paying Medicaid comparable rates. CHC will also keep an accurate and accountable inventory of pharmaceuticals. CHC’s policies and procedures will dictate how medication is dispensed, disposed of and tracked. CHC has the expertise to keep up with medical bills and ensure that no bill is significantly past due and is paid in an appropriate time frame.

FINAL RESPONSES OF SHERIFF DARR:

I have been the Sheriff for approximately 5 years and over those years the DOJ has not expressed any concerns of inmate’s treatment and care. As a matter of fact, the DOJ medical analyst commended Mr. Morris on his care and treatment of inmates. Although there have been some issues with invoice control, the privatization of the clinic should eliminate this problem in the future. The majority of all issues raised in the audit will be handled by the privatization of the clinic.

o Evaluation Plan
Develop the required annual evaluation plan to submit with the FY 2014 Annual Operating Plan, as well as FY 2016 Strategic Operating Plan, by the deadline assigned by the CCYFC. Plans must meet the guidelines develop by the state Family Connection Partnership and CCYFC.

o Data Collection Instruments
Develop new tools and/or modify existing local data collection instruments, if needed.

o Data/Databases
Provide training and written procedures for data collection tasks, if needed.

o Data Analyses
Analyze and determine possible applications for future strategic planning. Make program recommendations concerning the implications of the data findings and strategic approaches to said applications.

o Evaluation Reports and Presentations
Prepare interim reports and required annual results evaluation report to the CCYFC by the deadlines assigned by the CCYFC, typically due in mid – August or early September following the end of the fiscal year. Present the annual evaluation plan and the annual results report to the Board of Directors, Executive Committee and/or Evaluation Committee prior to submitting to any other agency or organization.

o Participation in Evaluation Training and Capacity Building
Attend collaborative, committee, and/or management team meetings based upon the Contractor’s availability and contracted hours purchased by the collaborative.