DIDD Audit Highlights Accomplishments, But Reveals New Concerns and Old Ones

By Janet Shouse

About the Author

Janet Shouse is a parent of a young adult with autism, and she is passionate about inclusion, employment of people with disabilities, medical issues related to developmental disabilities, supports and services, public policy, legislative initiatives, advocacy, and the intersection of faith and disability. She wears many hats at the Vanderbilt Kennedy Center, including one as a disability employment specialist for TennesseeWorks.

Our hope is that this blog will offer information you want to know, so if you have a question you want answered about employment for people with disabilities or other mysteries of the world of work, please email me at janet.shouse@vumc.org.

One of the state agencies with which we at TennesseeWorks work most closely is the Tennessee Department of Intellectual and Developmental Disabilities.

DIDD spearheads the Governor’s Employment First Task Force and also has a leadership role in Tennessee being named a Core and Community of Practice State in the Employment First State Leadership Mentoring Program for the 6th year by the U.S. Department of Labor’s Office of Disability Employment Policy.

You may also know that DIDD oversees supports and services to approximately 7,900 Tennesseans with intellectual disabilities through three Medicaid waivers, which are now closed to enrollment.

I realize that those 7,900 individuals receiving services through DIDD represent just a fraction of the number of Tennesseans with intellectual and developmental disabilities who need supports and services, but I still think it’s important for people to know how the Department of Intellectual and Developmental Disabilities is performing.

The Office of the Comptroller regularly audits every state department, generally every four years, and reports its findings to members of the Tennessee General Assembly. A performance audit, according to the state’s website, is “an independent examination for the purpose of reporting on the extent to which agencies and departments of state government are faithfully carrying out the programs for which they are responsible. The audit reports assist the General Assembly and state executive management:

  • by assessing the extent to which state agencies have fulfilled their statutory mandate and the efficiency and effectiveness of management’s organization and use of resources;
  • by developing recommendations for management or legislative action that might improve the efficiency and effectiveness of the agency’s operations; and
  • by providing pertinent program and financial data about the agencies.”

The stated mission of the Comptroller’s Office is to make government work better.

So, this year, the Comptroller’s Office audited DIDD and the related Statewide Planning and Policy Council from June 1, 2013, through June 30, 2017. The full audit, which was released on Nov. 29, can be found here.

While I know folks can simply go to the link above and read the audit themselves, (and I would be very happy if they did, I think it might be useful to highlight some of the results. I have listed them in the same order as they appear in the audit. The page numbers refer to the audit itself.

Key Findings

  • DIDD did not provide case management to individuals on the Medicaid waiver waiting list according to policy, did not make adequate attempts to communicate to individuals and families on the waiting list information about the new “aging caregiver legislation,” and again did not maintain the current needs status of supported individuals. (page 29)
  • Concerns emerged before, during, and after the launch of the new Medicaid waiver program, Employment and Community First CHOICES, which is administered through TennCare rather than DIDD. (page 47)
  • The Office of Risk Management and Licensure did not perform annual reviews of problematic areas identified in our prior two audits, leading to nine repeated findings (page 81).
  • For its employees directly caring for individuals with intellectual disabilities, DIDD did not perform background checks; sex offender, abuse, and other registry checks; and work history and credentials checks in a timely manner or at all. (While most of the individuals supported through the DIDD waiver programs receive their supports and services through community provider agencies, individuals who were either still in one of the state’s developmental centers or who moved out into state-supported “community homes” receive their supports and services through direct employees of DIDD.) (page 93)
  • DIDD did not keep track of who volunteered at its facilities; it either performed criminal background, sex offender registry, abuse registry, and work history checks late or not at all; and it accessed sensitive information about volunteers without permission. (page 100)
  • DIDD and its providers did not always complete required death reviews in a timely manner. (page 106)
  • Continued weaknesses exist within the system that DIDD designed to ensure that individuals with intellectual disabilities receive high-quality care. (page 115)
  • DIDD’s policy for granting exemptions for people with criminal records to work with vulnerable individuals contains both design and implementation flaws. (page 123)
  • As noted in findings for the last 14 years, the department did not implement the internal controls necessary to keep track of the belongings of individuals under its care. (page 143)
  • Because of the department’s inadequate monitoring, some individuals’ account balances exceeded the maximum allowable amount, risking loss of Medicaid eligibility. (page 162)

Observations

The state audit included these topics because of the effect on the operations of DIDD, the related Statewide Planning and Policy Council, and the people of Tennessee:

  • DIDD and the Division of TennCare collaborated to launch a new program—Employment and Community First CHOICES—to fill critical gaps in the state’s service delivery system. (page 40)
  • DIDD actively participates in federal and state integrated employment initiatives but has only recently begun collecting comprehensive data to evaluate its success. (page 78)
  • Department policy does not clearly differentiate between volunteers and visitors. (page 105)
  • Since its monitoring tool was populated incorrectly, the department runs the risk of incorrectly assessing whether a provider is compliant or noncompliant. (page 122)
  • After 23 years and more than $18 million spent, DIDD has progressed toward replacing its antiquated Community Services Tracking system, despite suffering additional setbacks and missed deadlines since the last audit. (page 171)
  • Infrequent meeting attendance by some Statewide Planning and Policy Council members might lead to the voices of the membership category they represent remaining unheard. (page 185)

Achievements

The report also lists several achievements of the department since June 2013, which include:

  • Resolving the Arlington lawsuit. In January 1992, the U.S. Department of Justice sued the State of Tennessee for violations of the Civil Rights of Institutionalized Persons Act at the Arlington Developmental Center. This case is known as United States v. State of Tennessee (Arlington). As a result of the lawsuit, the U.S. District Court ordered the facility to correct subpar conditions and appointed a court monitor. The state ultimately moved Arlington residents into community settings, and closed Arlington Developmental Center in 2010. On Oct. 31, 2013, the department completed the Arlington exit plan, and the court issued an order dismissing the case on Dec. 4, 2013.
  • Earning Council on Quality and Leadership Accreditation. The accreditation process consists of three important tools:
  1. Basic assurances – ensure accountability for health, safety, and security;
  2. Personal outcome measures – identify people’s quality of life outcomes, plan Supports, and gather information and data about individual outcomes; and
  3. Eight key factors and 34 success indicators for organizational excellence – define quality in terms of person-centered supports and services.
  • Developing the Intellectual and Developmental Disabilities Health Care Toolkit (IDDtoolkit.org).
    • An online resource for medical providers to better serve adults with IDD
    • A partnership of DIDD, the Vanderbilt Kennedy Center and the University of Tennessee Boling Center
    • Funded by the Special Hope Foundation (now the WITH Foundation)
    • (And I serve as the program coordinator for this project!)
  • Conducting law enforcement training.
  • Closing the Clover Bottom Developmental Center in 2015.
  • Closing the Greene Valley Developmental Center in 2017.
  • Resolving the People First In December 1995, People First of Tennessee v. Clover Bottom Developmental Center challenged the conditions at the Clover Bottom Developmental Center in Nashville, the Nat T. Winston Developmental Center in Bolivar, the Greene Valley Developmental Center in Greeneville, and the Harold Jordan Center in Nashville. With the closure of Greene Valley in May 2017, the state fulfilled the last term of the exit plan. On Sept. 8, 2017, the U.S. District Court dismissed the lawsuit, ending 25 years of federal litigation.
  • Opening a Mobile Seating and Positioning Clinic. The department already operated seating and positioning clinics in Greene, Davidson, and Shelby counties to provide custom wheelchairs and positioning equipment to individuals with intellectual and developmental disabilities. Tennessee’s budget for fiscal year 2017 included $398,500 in state funds for the department to establish a mobile seating and positioning clinic unit to bring services to individuals unable to travel to the existing clinics. The department received the mobile clinic on June 1, 2017.

There was one “emerging issue” listed in the Comptroller’s audit, and that is the critical shortage of caregivers, known as direct support professionals, for those with intellectual and developmental disabilities. I will write about that concern in the Feb. 6 edition of “Rise to Work.”

The audit includes two maps showing where people who are supported by the DIDD Medicaid waivers live. One map shows which Tennessee Senate districts they live in, and one shows which House district they live in. You may ask why would these maps be necessary. The reason is that lawmakers care about how things affect people in THEIR districts, the people that they represent. These maps let the senators and representatives see how many people with intellectual disabilities receive Medicaid waiver supports and services are in their own districts.

If you have questions about the audit, I will try to find answers. Or, if you would like to share concerns, please email me at janet.shouse@vumc.org.