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YELLOW SHEET Office of the State Auditor of Missouri |
Report No. 2005-62
September 2005
State mental health clients not fully protected from abuse and neglect due to problems with incident investigations and abusive workers still employed
This audit reviewed how well the Department of Mental Health tracks, investigates and handles incidents and investigations of individuals committing abuse or neglect against its 140,000 clients. All such allegations, including client deaths are tracked in the department's Incident and Investigation Tracking System, which reported 5,689 incidents from July 2003 through August 2004. This audit also followed up on recommendations from a 2001 audit and found systemic problems with abuse investigations.
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Only 2 of 8 previous audit recommendations implemented |
As of June 2005, only 2 of 8
recommendations from the previous 2001 audit report had been
implemented. The 2001 audit found regulations did not fully protect
clients from physical aggression and injuries. Follow up audit work
showed: providers did not submit all incident reports to the department
for the tracking system, not all regional centers tracked incident
reports, and the department did not track client on client abuse. As a
result, the department and regional centers could not identify abuse
trends and patterns. In addition, department officials did not act on
2004 department internal reviews, which made suggestions to correct
problems in the existing system. (See pages 4 and 9)
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Continuing to employ known felons led to more abuse |
Auditors found criminal background check
procedures were not always followed, which led to further abuse. In one
case, a state-run facility did not immediately fire an employee when a
background check showed multiple felonies. During the 12 days between
knowing the background check results and the employee's termination, the
employee sexually abused a client. (See page 19)
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Employees who previously abused clients were still working |
Auditors found 38 individuals listed
on state employee disqualification lists - which list
abusive/neglectful employees - still working with mental health
clients between April 2003 and April 2005. Auditors found these
individuals by doing an automated match between employee
disqualification lists and state employment records, a match never
done before by the department. In addition, auditors found the process
to put a disqualified employee on the list too slow. In one case, a
regional center did not place a disqualified employee on the list
until 2 years after the alleged abuse occurred. In the meantime,
another provider hired the employee, who then neglected and verbally
abused another client. (See page 20)
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Abusive provider still allowed to run facility until audit |
Department officials had continued to
contract with a provider owned by persons who had been on the
disqualification list since March 1999. During that time, 11
substantiated cases of neglect occurred at this home, including one
client's death. Although department officials knew the owners were on
the list, they did not initially think they had the authority to revoke
the provider's certification. After auditors shared concerns about this
provider, the department removed all clients from the home and did not
renew the provider's contract. (See page 22)
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Abuse investigations lack independence and consistency |
Auditors found investigators employed at
the mental health facilities - rather than independent investigators
from outside the facility - conducted 89 percent of the abuse and
neglect investigations. Investigations were also inconsistent with each
facility having its own investigative process and investigation outcomes
differing depending on the facility. Since the audit, department
officials have completely revamped the investigative process, including
requiring outside, independent investigators. (See page 17)
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