YELLOW SHEET Office of the State Auditor of Missouri Claire McCaskill

 

March 15, 2001

Report No. 2001-20

Missourians with developmental disabilities who rely on contractor-operated �facilities �are not well protected from acts of physical aggression by other clients or from medication errors. 

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Inadequate monitoring by the state�s 11 regional centers over contractor-operated facilities, which provide day programs and residential environments to nearly 9,000 developmentally disabled, leave clients and staff at risk.  A complaint made to our office alleging mismanagement at one such facility prompted this audit.  The review included an analysis of incident and injury reports of eight contractors operating in five of the state�s regional centers.  The following highlights our findings:

Injury and incident reports not reviewed 

An analysis of 4,400 incident reports over an 18-month period showed hundreds of acts of physical aggression between clients, or between clients and staff, �which resulted in more than 1,000 injuries. �(See page 2) But no one in the state knew the true nature of this problem until this audit because such reports were not being reviewed, computerized to track trends or even kept � one facility threw out� the reports. (See page 11) 

Part of the inconsistent handling of such reports is due to weak state law that does not require contractor-operated facilities to thoroughly document the incidents or submit them for review.  

Review would allow a facility to track trends. Our analysis showed that often only a few clients are involved in the alleged physical aggressions. �(See page 13) In one case, a client committed 65 acts of aggression against her roommate in 18 months. (See page 5) Trending would have allowed state staff to identify this situation quickly and correct it. 

Contractors held to lower standard on aggressive clients 

State regulations on managing behavior of an aggressive client considered dangerous to others or themselves do not apply to contractor-operated facilities. �State regulations require a �dangerous� client to receive one-to-one or high priority supervision.� Our analysis of incident reports at contractor-operated facilities showed numerous clients fit the �dangerous to other or themselves� definition. �In one facility, 16 clients were physically aggressive with other clients or staff two or more times in a short period. �But because these contractor-operated facilities are not held to this same standard, their �dangerous� clients do not receive the necessary supervision. (See page 4) 

Medication errors go unreported 

Contractor-operated facilities are not required to immediately report to regional centers if clients were not given their prescribed medication, an act that is required of state-run facilities. �Contractor-operated facilities are only required to report an injury or incident, which could include a medication error. �Our review of these incident reports showed a substantial number of medication errors, including 903 medication errors over 18 months at one facility. �Such errors included failing to dispense medications or dispensing them late.� Since we could only track medication errors through incident or injury reports, it is unknown how understated or widespread the error really is. �(See page 6).   

Inconsistent record-keeping makes monitoring difficult 

Our tests showed that contractors used a variety of formats to report incidents.� A standard format for all contractors is needed to facilitate managing a database of incident reports at the regional centers.� This database would allow the state to trend incidents, evaluate a contractor�s performance and identify clients that need to be removed from their current setting. (See page 11) 

Complete Audit Report

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Missouri State Auditor's Office
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