Carolyn N. Graham, Deputy Mayor for Children, Youth and Families, for the Executive Office of the Mayor
Testimony to the DC City Council Committees on Governmental Operations and Human Services on
The Mental Retardation and Developmental Disabilities Administration
May 18, 2000

Home

Bibliography

Calendar

Columns
Dorothy Brizill
Bonnie Cain
Jim Dougherty
Gary Imhoff
Phil Mendelson
Mark David Richards
Sandra Seegars

DCPSWatch

DCWatch Archives
Council Period 12
Council Period 13
Council Period 14
Election 1998
Election 2000
Election 2002

Elections
Election 2004
Election 2006

Government and People
ANC's
Anacostia Waterfront Corporation
Auditor
Boards and Com
BusRegRefCom
Campaign Finance
Chief Financial Officer
Chief Management Officer
City Council
Congress
Control Board
Corporation Counsel
Courts
DC2000
DC Agenda
Elections and Ethics
Fire Department
FOI Officers
Inspector General
Health
Housing and Community Dev.
Human Services
Legislation
Mayor's Office
Mental Health
Motor Vehicles
Neighborhood Action
National Capital Revitalization Corp.
Planning and Econ. Dev.
Planning, Office of
Police Department
Property Management
Public Advocate
Public Libraries
Public Schools
Public Service Commission
Public Works
Regional Mobility Panel
Sports and Entertainment Com.
Taxi Commission
Telephone Directory
University of DC
Water and Sewer Administration
Youth Rehabilitation Services
Zoning Commission

Issues in DC Politics

Budget issues
DC Flag
DC General, PBC
Gun issues
Health issues
Housing initiatives
Mayor’s mansion
Public Benefit Corporation
Regional Mobility
Reservation 13
Tax Rev Comm
Term limits repeal
Voting rights, statehood
Williams’s Fundraising Scandals

Links

Organizations
Appleseed Center
Cardozo Shaw Neigh.Assoc.
Committee of 100
Fed of Citizens Assocs
League of Women Voters
Parents United
Shaw Coalition

Photos

Search

What Is DCWatch?

themail archives

On behalf of Mayor Anthony A. Williams, we are pleased to come before you today, to present testimony on behalf of the executive branch of the government at this the conclusion of your intensive review of senior administrators' roles in the conduct of business associated with managing urgent and emergent issues of the mental retardation and developmental disabilities administration. And coincidentally, at the near conclusion of the Williams' administration's own multifaceted assessment of the entire system of services for persons with Mental Retardation and Developmental Disabilities in the District of Columbia.

Upon Mayor Williams' assumption of office in January 1999, he stated his unwavering commitment to making the government of the District of Columbia responsive to the needs of the most vulnerable of our citizens. It is no mystery to anyone that the Williams' administration inherited a government that was almost completely decimated as a result of years of disinvestment, mismanagement, and poor performance. Upon assuming responsibility for this government, Mayor Williams gave agency leaders the opportunity to begin the organizational restorative process by implementing a series of short-term action initiatives aimed at meeting the needs of District of Columbia residents being served.

The Director of Human Services showed a commitment to serious reform efforts. She embraced Mayor Williams' call for accountability and results, and she showed a sense of urgency about improving services to vulnerable people. The Director of Human Services delivered results in 1999, by achieving many of the short-term targets identified as making a difference in the quality of government, and the quality of life of the District's residents.

The Executive Office of the Mayor supported the Department of Human Services on a path to accountability and excellent customer service, and helped the agency when problems arose. Issues raised by the leadership in the Department of Human Services indicated that although problems existed in MRDDA, and in other administrations in the organization, Director Williams was on top of them, no threats to life or safety of individuals in government care were identified, and all situations in the Department were under control.

There were multiple mechanisms for communication between the Executive Office of the Mayor and agency directors. Agency directors attended weekly cabinet meetings with the Mayor, the Deputy Mayor for Operations/City Administrator, and the Chief of Staff where they could raise concerns both within their own agency and across-agencies. Another way that agency directors discussed problems and their strategic plan was through monthly meetings with the Deputy Mayor for Operations/City Administrator. Also, if agency directors felt that they were not getting sufficient response to serious problems, they could reach the Mayor directly, 24 hours a day, seven days a week, by contacting the Mayor's Command Center.

Since these mechanisms were not used to convey issues emerging in the Department, there were no indications that would lead the Executive Office of the Mayor to doubt the Department's leadership, given its performance on major initiatives accomplished and its demonstrated commitment to government reform.

The Department of Human Services (DHS) reported to the Executive Office of the Mayor (EOM) that to the extent problems existed in MRDDA, they were under control:

• In February, 1999, DHS informed the EOM of a proposed Washington Post article about problems of poor care provided at group homes, the cause of system failures, and other issues. DHS further indicated that many, if not all of the problems of the past were being addressed as part of its sweeping organizational reform.
• In a memo to Mayor Williams in February 1999, the Director of DHS expressed confidence that her, "staff has continued to address all of the areas of concerns we expect will be presented in the article." DHS also forwarded to the EOM a consultant's assessment of MRDDA, and the MRDDA Five Year Plan. DHS also referred to a "corrective action plan" that was in place to address issues raised by the report.
• In June 1999, DHS notified the EOM of the death of a client while in the care of a transportation contractor and indicated that it was working with and fully cooperating with the Department of Health's investigation to ensure that procedures would be established to prevent similar incidents. In four subsequent written communications with the Department of Health, the EOM closely monitored the investigation and emphasized the need to immediately implement corrective procedures.
• Informing the EOM of "another death" of an MRDDA client in a Frontburner report of June 24, 1999, DHS indicated that there was a full investigation already underway regarding the incident. The Director of DHS also indicated that she would apprise the EOM of conclusive information once it was received, but that there was no reason to suspect foul play at that time.
• An August 26, 1999 Frontburner Report indicated that MRDDA needed legal representation in guardianship hearings. Staff in the Office of the City Administrator contacted the Office of the Corporation Counsel (OCC) to inquire about status of legal representation at hearings. OCC had already acted to resolve the problem.
• As late as December 1, 1999, DHS indicated. that it had MRDDA issues under control. In a letter sent to several District leaders and MRDDA stakeholders, the Director of DHS described the steps that were taken to improve services, including increased monitoring and information sharing between agencies, and the Evans exit strategy planning group. She wrote: "We believe these initiatives, coupled with other planned program changes, will continue to provide immediate and long term improvements."

However, when the EOM learned of serious MRDDA issues, EOM took immediate action.

• In March, 1999, the Director of DHS told the EOM of problems with an MRDDA provider who was using clients for manual labor and housing them in inappropriate facilities. Subsequently, when the Deputy Mayor for Operations/City Administrator learned that the clients had not been removed from the problematic provider, he instructed the Director to remove clients from problem homes immediately. The contract with this particular provider was subsequently terminated on March 16, 1999.
• The May 6, 1999 and June 10, 1999 Frontburner reports indicated that MRDDA was having trouble with getting contracts processed in a timely manner. The Deputy Mayor for Operations/City Administrator spoke with the Chief Procurement Officer to discuss improvements needed in DHS contracting and insisted that the procurement process for critical human service issues be expedited.
• In June, 1999, the Director of DHS raised the issue of civil commitment of mentally retarded persons. There was legislation pending in the Council on the issue and there was a customer in MRDDA for whom competency was raised as an issue. The Office of the City Administrator provided information to the Director of DHS so that she could develop long-term solution to the issue. Ultimately, the Council withdrew proposed legislation after the Mayor asked that a vote be postponed until hearings could be held to consider the impact on mentally retarded persons, policy implications for the District, and the fiscal impact of the legislation.

Upon learning that problems were even more egregious than originally and subsequently described, the EOM again took immediate actions to address MRDDA health and safety issues. The public record establishes that during 1999, the U.S. Department of Justice was investigating MRDDA and had issued a report raising health and safety concerns about several class members. In addition, the Office of the Inspector General was asked by the DHS Director to perform an audit in 1999 concerning health and safety of clients. The Director of DHS and her General Counsel were fully aware of these investigations but did not inform the Executive office of the Mayor.

In December, 1999, the EOM assembled a team to aggressively review the MRDDA service delivery system including the Department of Human Services, Department of Health, and all licensing and regulatory agencies.

A January 21 memo transmitting the preliminary report recommended further investigation of various governmental entities, including the Executive Office of the Mayor, the Office of Communications, the Office of the Inspector General (OIG), the Department of Health (DOH), the Department of Human Services, Metropolitan Police Department (MPD), Office of the Chief Medical Examiner (CME), D.C. Public Schools (DCPS), employees currently on administrative leave pending further evaluation, and the City Council.

The report suggested that the entire mental retardation and developmental disabilities system was fundamentally unable to deliver even the must basic services. The team's report helped in the development of the MRDDA 90 Day Plan to Build a Comprehensive and Competent Developmental Disabilities Service System.

As we work to build a new system, it is important to understand why and how the old system failed. We began with a thorough examination of: the philosophy of service, our methods of doing business, our system of procurement and the capabilities of our provider agencies and their staffs, the ability and training of government workers, our approach to quality assurance, service coordination, monitoring, tracking and other issues.

Based on our work over these past 90-days, we can say fairly definitively that the current system failed because of a poor design and years of neglect and disinvestment by a community and a government that found it easy to forget those who were voiceless. The system intended to address the needs of those with developmental disabilities suffers from fundamental problems that must be remedied immediately:

• There are no clearly defined quality service standards;
• No quality improvement process;
• No significant penalties for lack of compliance with existing system's requirements;
• Fragmentation and coordination in government business processes;.
• No investment in technology to augment business processes internal and external to government;
• A poorly trained workforce both in and outside of government;
• A highly inconsistent, underpaid workforce external to government;
• Limited supported employment opportunities. Well over 60% of the population in CRF's could benefit from such opportunities; and
• A system that favors high cost institutional-based care in opposition to a system that supports and encourages independence and inclusion.

Madam chair, some have said that the involvement of many agencies in this work is what has led to the management breakdown. I would suggest to you today that the very nature of human services requires the involvement of multiple agencies working together. The MRDDA function is no exception.

What we have accomplished

Over the last 90 days, we have mounted an aggressive, rapid effort to improve the MRDDA system and remove imminent threats to life and safety. While the system requires a major overhaul that will not happen overnight, we have already made major progress in three areas:

1. We have stabilized the current system and significantly reduced the risk of harm to individuals in the system;
2. We have conducted extensive evaluation to determine the reasons why the current system failed;
3. We have laid the groundwork for a new state-of-the-art system.

Let me give you a few highlights in each of these areas.

A. Stabilization and Reduction of Risk to Individuals in the System:

• Each week, I personally facilitate a forum where all agencies -- the Office of Corporation Counsel, the Department of Health's Medical Administration Agency and Health Regulations Administration, the Department of Human Services' Mental Retardation and Developmental Disabilities Administration, Adult Protective Services, the Office of Inspections and Compliance; the Office of the Chief Technology Officer, the Metropolitan Police Department -- involved in the work associated with persons with mental retardation and developmental disabilities, meet regularly to coordinate services. We identify critical areas of work and rapidly map out appropriate responses. We focus on emergent and urgent issues requiring cross-agency action, and develop solutions ranging from new policies and procedures to designing an integrated management information tracking system. This is the kind of collaboration that was absent in the past but exists today.
• A weekly mortality report is now prepared and monitored closely, death certificates are retrieved and become part of the permanent record prior to file closure.
• All deaths now are referred to the medical examiner for autopsy.
• An adult fatality review committee has been established. The committee will review all deaths of persons over 18 years of age who die in the District's care.
• An outside contractor was retained to individually determine the medical well being of individuals in the system. Thus far, individuals in community residence facilities, all large day treatment facilities covering about 60% of individuals in these treatment programs, and approximately 75% of the individuals in institutional (intermediate) care facilities have been reviewed. By the end of this month, all individuals will have been evaluated.
• We have assessed the status of about 90 percent of persons living in community residential facilities and their eligibility for a home and community based Medicaid waiver. This work is complete, and provider deficiencies identified. Providers will either comply with our improved standards, or be. removed from the system.
• Another major accomplishment of the last 90 days is that unusual incident reports are now collected daily and stored in a MIS system for analysis and follow-up.
• Furthermore, new policies and procedures have been developed and implemented for appropriate follow-up of all incidents, including notification of the Chief Medical Examiner and Metropolitan Police Department in the event of death.
• Additionally, two federal investigators are on board, working with the Office of Investigations and Compliance staff to train staff to manage Unusual Incident Reporting and to address the existing backlog of unprocessed reports.
• For the first time in 23 years, the city is up to date in responding to the courts and court monitor's reports.
• High-risk providers have been identified and persons in their care assessed. Physicians have reviewed risk situations including problems involving the interaction of multiple medications - an all too common phenomenon in this system.
• Contracts now require background checks for employees, especially drivers, for both Medicaid funded providers and District contracted providers.
• All purchase orders for CRF services have been eliminated, contracts issued, and preparations are underway for new solicitations.
• All employees in MRDDA have been evaluated for general competencies related to their positions. Case mangers are currently being assessed for competencies in their discipline, and individual training plans are being developed to address short-term, immediate needs.
• All providers are being reviewed by the Office of Operational Improvements to determine their general competency and ability to provide high quality services. Among the challenges to be overcome by providers are low pay, poor staff training, high turnover, no mandatory background checks of employees, and a lack of standardized training requirements across the system.
• Immediate, substantive skill training to mitigate risk factors was provided to high-risk providers, and to all MRDDA staff by a nationally-recognized leader in the training of developmental disabilities staff. Training by these providers is continuing.
• The Council on Quality and Leadership, an international leader in quality services for people with disabilities, is completing a study of the case management system and making specific recommendations for its complete overhaul.

While we have accomplished much over the last 90 days, far more remains to be done.

We have already begun a new system of services. It is a system that will work and will give us the outcomes that we desire as a community for persons with disabilities: dignity, productivity, independence, self-determination, and inclusion.

Based on recommendations from a number of sources: the Evans Exit Planning Committee, the MRDDA Internal Coordinating Committee, an understanding of best practices in New York State, Maryland, Michigan and Minnesota, we've begun to lay the foundation for this new system whose tenets will be, at a minimum, based on some of the following principles:

• Services and supports for persons with developmental disabilities will be customized and relevant to their life goals;
• Services will respect the rights and dignity of all individuals and incorporate the culture and value system of the individual;
• Services will include an array of flexible supports that respond to the changing needs and preferences of the individual and family;
• Funding will follow the individual, rather than the program or institution;
• There will be trained lay advocates who assist individuals as necessary, to make informed choices;
• Service coordinators (case managers) will act as advocates and change facilitators on behalf of individuals using the system of services.

Funding of the new system will use both federal and local resources to fund individuals rather than "slots" or beds in the system. A growing share of the system's costs will be underwritten by federal dollars through the use of the Medicaid Home and Community Based Waiver for which we have applied. We are now working with the Department of Health and Human Services to structure the waiver so it meets the discrete needs of persons with disabilities. The District's Waiver Request has been designed to include occupational and physical therapy, nursing care, assistative technology, family training, adaptive aides, and companion services.

Within the next week, the Mayor will send legislation to the Council create an independent quality assurance monitoring commission as well as legislation to fundamentally change the governments role in the MRDD system.

The independent monitoring commission will have broad oversight responsibility over the entire system of services, including government and the private sector. It will be a 501 (C) 3 whose members are appointed by the Mayor and confirmed by the Council.

The commission has three functions: monitoring, advocacy, and planning and research.

First, the Commission will serve as an independent quality of care monitor, conduct investigations as it sees fit, and aggressively press for equity, fairness, the protection of individual rights, and quality in all services.

Second, the Commission will be empowered and staffed to protect the rights of people with developmental disabilities through both a Lay Advocacy branch and a Legal Advocacy branch.

Third, the Commission will be charged with gathering information and planning for future needs of the population with mental retardation and developmental disabilities. It is our belief based on anecdotal data - that the MRDD population will grow substantially over the next ten years.

Within the next week we will also send legislation to the Council to expand our authority to outsource or use managed competition for most of the services in this area that government does poorly. Painful experience has taught us that government currently lacks the capacity to adequately deliver these services.

As the legislation moves forward, we will closely consult with all of the appropriate stakeholders, including organized labor, to ensure that they are part of the decision making process.

We will radically redefine and reduce the government's role, focusing our efforts on expanding options for individuals and their families, and providing the proper oversight and enforcement that we need to protect the health and well-being of our people. Moving forward, government will do three things:

First, we will create new alternatives to group homes, providing individuals and their families with a full range of options. We will give them the freedom to choose services for themselves. The Medicaid Waiver program and the flexible funding strategies it allows will help the District to move down that road. The system works best when funding follows people not institutions

Second, we will establish strong and effective legislation and regulation to provide quality oversight for people in our care. We must ensure that residents are safe and that providers follow national best practices.

And third, we must enforce our laws. Threats to life and safety must be met with strong investigation and intervention. We must live up to our legal and moral obligation to protect our vulnerable citizens.

Obviously, our approach requires a renewed public-private partnership to reinvigorate our service system. By the end of this month, under the master services agreement, we will launch a solicitation to dramatically increase the number of private sector partners who can provide a variety of high quality services. We want the city's best providers to offer new services that meet needs and lead to desired, measurable outcomes.

The new system of services cannot be designed without the active involvement of those it will serve: individuals with disabilities and their families. We are committed to this principle.

Finally, others from the private sector must be involved in making the District home for people with developmental disabilities and their families. A true partnership must include educating the next generation of leaders and direct support professionals who will work in this system. The business community must provide more jobs and more opportunities for promotion. Housing developers and lenders must assist in providing low-cost, safe housing for all members of our community who desire to live in their own home. And of course, elected and appointed officials must work together toward one goal of a new commitment to our most vulnerable citizens.

This now concludes our testimony. We will be happy to answer questions at this point.