Biennial report, 2018-2019

Biennial Report
Jacquice Stone Georgia Disability Services Ombudsman and Olmstead Coordinator
Mission Statement: The mission of the Office of the Disability Services Ombudsman (ODSO) is to promote the safety, well-being, and rights of individuals with disabilities and to coordinate state compliance with the 1999 US Supreme Court Olmstead decision (O.C.G.A. 37-2-35).

Office Location:

7 Martin Luther King, Jr. Drive 4th Floor, Suite 443 Atlanta, GA 30334
Toll Free: 1-(866)-424-7577 Phone: (404) 656-4261
Website: www.dso.georgia.gov Email: odso@georgia.gov

Biennial Report Objective: Georgia law stipulates that the biennial report should document the types of complaints and problems reported by consumers and others on their behalf and include recommendations concerning needed policy, regulatory, and legislative changes (O.C.G.A. 37-2-35).

FY 2018 - FY 2019 BIENNIAL REPORT
Table of Contents
Message from the Ombudsman and Olmstead Coordinator ___________________________ 1 Responsibilities of the Office of Disability Services Ombudsman______________________ 3 Intake Overview ____________________________________________________________ 4
Intake Categories __________________________________________________________ 5 FY 2018: Intake by Department of Behavioral Health and Developmental Disabilities (DBHDD) Service Regions ___________________________ 6 FY 2019: Intake by Department of Behavioral Health and Developmental Disabilities (DBHDD) Service Regions ___________________________ 7 Disability Populations ______________________________________________________ 7 Complaints Received ________________________________________________________ 9 Complaint Issues __________________________________________________________ 9 Complaint Outcomes_______________________________________________________11 Assistance and Information Requests ___________________________________________ 12 Most Frequent Issues: Assistance and Information Requests _______________________ 13 Medical Review Group (MRG) _______________________________________________ 14 MRG Meetings _________________________________________________________ 154 Medical Review Statistics _______________________________________ 15_Toc443052936 Policy, Regulatory, and Legislative Changes _____________________________________ 16 Changes Implemented During the Biennium ___________________________________ 16 DBHDD Map of Service Regions ____________________________________________ 18 Appendix B Medical Review Group Legislation_________________________________ 19 Appendix C Acronyms_____________________________________________________ 21

Message from the Ombudsman and Olmstead Coordinator
To Governor Brian Kemp, the General Assembly, Commissioners, and the general public:
It is my honor to serve as Ombudsman and Olmstead Coordinator, a position I assumed on March 13, 2019. The Office of Disability Services Ombudsman (ODSO) combines the roles of Ombudsman and Olmstead Coordinator and fully embraces the mission of promoting the safety, rights, and well-being of individuals with disabilities in Georgia. This office responds to complaints and requests for assistance and information while also working to support community integration and consumer choice in accordance with the U.S. Supreme Court's 1999 Olmstead decision.
The enclosed report provides an account of the work accomplished by ODSO and the Medical Review Group during fiscal years 2018 and 2019. Within this biennium, the ODSO saw a 51 percent decrease in the total number of issues raised by complainants. The majority of inquiries received were from or on behalf of individuals living with a mental illness.
Of note, since the submission of the previous report in 2017, ODSO has been monitoring efforts by the Department of Behavioral Health and Developmental Disabilities (DBHDD) to expand community-based capacity and transition individuals from institutional settings into the community. In 2013 and 2015 respectively, the department closed Southwestern State Hospital and the James B. Craig Nursing Center. This work to support community integration aligns with ODSO's priorities.
ODSO seeks to partner with federal, state, and local agencies and stakeholders to improve service delivery for all disability populations in Georgia. We reaffirm our commitment to listening to the disability community and the general public to identify issues and determine effective solutions. Thank you for your interest and support of the work of the Office of Disability Services Ombudsman.
1

Sincerely, Jacquice Stone Ombudsman and Olmstead Coordinator Governor's Office of Disability Services Ombudsman
2

Responsibilities of the Office of Disability Services Ombudsman1
Establishes priorities, policies and procedures for receiving, investigating, referring, and attempting to resolve complaints made by or on behalf of consumers concerning any act, omission to act, practice, policy, or procedure of provider of services that may adversely affect the safety, well-being, and rights of consumers and any policies and procedures necessary to implement the provisions of this article;
Investigates and make reports and recommendations to the department and other appropriate agencies concerning any act or failure to act by any provider of services with respect to the safety, well-being, and rights of consumers and is authorized to: (a) Prioritize investigations, reporting, and recommendations based on the seriousness and pervasiveness of the alleged act or failure to act; and (b) Refer to the services' provider those complaints deemed appropriate for resolution by the services' provider;
Establishes a uniform state-wide complaint process;
Collects and records data relating to complaints and findings with regard to services' providers and analyze such data in order to identify adverse effects upon the safety, wellbeing, and rights of consumers;
Promotes the interests of consumers before governmental agencies and seek administrative and other remedies to protect the safety, well-being, and rights of consumers by: (a) Analyzing, commenting on, and monitoring the development and implementation of federal, state, and local laws, regulations, and other governmental policies and actions that pertain to the safety, well-being, and rights of consumers; and (b) Recommending any changes in such laws, regulations, policies, and actions as the ombudsman determines to be appropriate;
Makes a biennial written report documenting the types of complaints and problems reported by consumers and others on their behalf and include recommendations concerning needed policy, regulatory, and legislative changes. The biennial report shall be submitted to the Governor, the General Assembly, the commissioner, and other appropriate agencies and organizations and made available to the public. The ombudsman shall not be required to distribute copies of the biennial report to the members of the General Assembly but shall notify the members of the availability of the report in the manner which he or she deems to be most effective and efficient. The report shall not identify any consumer by name or by implication without the express written consent of the consumer, or if applicable the parent of a minor consumer, the guardian of the consumer, or the health care agent of the consumer if the agent is so authorized to make such a decision and the consumer is unable to do so; and
Reports suspected criminal activity, abuse, neglect, exploitation, abandonment, or violation of professional code.
Coordinates and leads the medical reviews of all deaths in state hospitals and state operated community residential services.
Coordinates state compliance with the 1999 US Supreme Court Olmstead decision.
1 O.C.G.A. 37-2-35
3

Intake Overview

The Office of Disability Services Ombudsman (ODSO) responds to complaints as well as requests for assistance and information as it relates to the safety, well-being and rights of individuals with disabilities in Georgia. During the 2018 and 2019 fiscal years, ODSO opened 176 cases and responded to 178 issues. The issues responded to range from complaints of abuse and neglect to requests for assistance regarding housing for individuals with disabilities. From fiscal year 2018 to fiscal year 2019, there was a decrease of 42 percent in the number of issues responded to by the ODSO.

Complaints Assistance Requests Information Requests Total Issues
Figure 1

Top 10 Most Frequent Issues Across all Intake Categories
Benefits Housing Other Discharge Abuse/Neglect Legal Care Plan Transportation Medication Education Subtotal (10 most frequent issues) Total (of all issues responded to)
Figure 3

FY 2018 and 2019
66 28 24 20 14 7 5 5 2 2 173 178

176 15
84 77
15 13
77 36
84 126 176 175

Figure 2 2018 2019
Percentage
37.0% 15.7% 13.5% 11.2% 7.8% 3.9% 2.8% 2.8% 1.1% 1.1% 97% of total 100%
4

Intake Categories
Information Requests
Assistance Requests
Complaints

Calls to the Office of Disability Services Ombudsman (ODSO) often concern how to determine benefit eligibility or how to apply for a benefit. In most instances, these inquiries can be resolved by providing a telephone number or point of contact. ODSO staff routinely verify that the contact information is valid before providing it to a caller. ODSO staff continuously update the office's resource listing and points of contact to support individuals with disabilities.
Requests for assistance are more involved than requests for information and often require extensive work by ODSO staff. ODSO cannot provide legal, financial, or medical advice. ODSO staff will provide contact information for these technical services. If a caller has difficulty obtaining a benefit or service, ODSO staff can facilitate the connection to the agency responsible for the benefit, service, or support. These calls are not transferred to other helping agencies until ODSO has worked to resolve the request in the office and has provided the caller with a workable solution.
Complaints are regarded as more serious and normally require an investigation to determine if the complaint is substantiated or not. Although ODSO often works with state agencies to resolve complaints, ODSO is an independent office that is legislatively required to determine the facts in an investigation and take appropriate action to correct the situation and to prevent a future reoccurrence. ODSO makes its final determinations independent of any provider or state agency. Any call concerning the safety, well-being, and rights of an individual with disability is considered a priority.

5

FY 2018: Intake by Department of Behavioral Health and Developmental Disabilities (DBHDD) Service Regions2

Region 1 2 10 4

Region 2 2 6

15

Region 3 7

42

39

Region 4 1 4 4

Region 5 2 5 4

Region 6 1 4 8

Unknown/Other 2 2

0

10

20

30

40

50

60

70

80

Complaints Assistance Requests Information Requests

90 100

Figure 4

2 Map of DBHDD service regions can be found in Appendix A 6

FY 2019: Intake by Department of Behavioral Health and Developmental Disabilities (DBHDD) Service Regions3

Region 1 2 3 4

Region 2 5 8

Region 3 4

22

42

Region 4 2 2

Region 5 5 3

Region 6 1 3 9

Unknown/Other

14

14

0

10

20

30

40

50

60

70

80

Complaints Assistance Request Information Requests

Figure 5
Disability Populations
The Office of Disability Services Ombudsman (ODSO) serves all individuals with disabilities, their families, and those who provide support and advocacy. The table below lists the disability populations served during fiscal years 2018 and 2019 (Figure 4). Combined mental illness disabilities and physical disabilities accounted for the majority, 74 percent, of the ODSO's total intake during the biennium. This includes complaints reported by individuals with a disability or on their behalf, as well as requests for assistance and information. This information is useful in outreach planning, policy formulation, and legislative recommendations.

3 Map of DBHDD service regions can be found in Appendix A 7

Total Disability Population Served
Physical Disability Mental Illness None/Not Determined/Not Available Intellectual and Developmental Disability Brain Injury-Mental Illness Addictive Disease Co-Mental Illness and Addictive Disease Total Cases by Disability Type
Figure 6

FY 2018 FY 2019

48

47

86

78

16

36

20

14

3

0

0

0

0

1

173

176

Total Cases
95 164 52 34
3 0 1 349

8

Complaints Received

To emphasize the availability of

ombudsman services, the Office of

Disability Services Ombudsman

O.C.G.A. 37-2-39

(ODSO) has established a state-wide complaint process, distributed posters about the complaint process, and provided contact information for ODSO.

The ombudsman shall prepare and distribute to each services provider in the state a written notice describing the procedure to follow in making a complaint, including the address and telephone number of the office and the ombudsman. The

administrator or person in charge of such services

During the intake of complaints, ODSO

provider shall give the written notice required by

gathers and evaluates initial

this Code section to each consumer who receives

information from the complainant to

disability services from such services provider and

determine how to proceed in the

the consumers guardian, parent of a minor

investigation. This is primarily done

consumer, or health care agent, if any, upon first

through a phone intake process. Sixtyfive percent of cases involving issues of complaint are initiated directly by individuals with disabilities and the other thirty-five percent are initiated by relatives, agency personnel, and other advocates.

providing such disability services. The administrator or person in charge of such services provider shall also post such written notice in conspicuous public places in the facility, premises, or property in which disability services are provided in accordance with procedures provided by the ombudsman and shall give such notice to any consumer and his or her guardian, parent of a

During the complaint investigation process, ODSO looks for and analyzes the facts of each complaint issue. This

minor consumer, or health care agent, if any, who did not receive it upon the consumers first receiving disability services.

is done while also maintaining

impartiality as well as necessary confidentiality. All available sources of information are

considered, including: applicable laws, rules, regulations, policies and or procedures, important

documentation, and phone interviews. The range of issues investigated and an overview of the

complaint outcomes during fiscal years 2018 and 2019, follow.

9

Complaint Issues

The percentage of complaint cases
decreased by 51% from FY 2018 to
FY 2019.

Chart Title

The percentage of complaint issues
decreased by 53% from FY 2018 to FY 2019.
For reporting purposes, the number of complaint cases equals to the number of complainants. Therefore, ODSO not only tracks how many individuals report problems (complaint cases/complainants), but also the various problems that are reported by complainants (complaint issues).

20

18

16

14

15

12

10

8

6

4

2

0

FY 2018

18 13
FY 2019

Complaint Cases

Figure 7

Complaint Issues

FY 2018 and 2019 Issues of Complaints

12

10

8

6

4

2

0 Issues of Complaint
Abuse Neglect
Figure 8

Discharge

Housing

Care Plan

10

Complaint Outcomes
The investigation process involves communicating with state agency points of contact, and in some instances, private service providers who are not contracted with a state agency. Nonjurisdictional cases involving services not provided by or contracted through a state agency may rely more on the process of informal mediation to assist with resolving the problem(s).
Complaints are substantiated if information received during the investigation supports the allegations presented. If the investigation does not support the allegations, the complaint is unsubstantiated. If ODSO staff is unable to obtain information to make a substantiated/unsubstantiated determination, the complaint is reported as inconclusive. As reflected in Figure 9, the majority of complaints investigated during fiscal years 2018 and 2019 were unsubstantiated. However, an unsubstantiated outcome does not mean that there are no presenting issues that need attention and does not discourage the ODSO from working with the reporter beyond the investigation to determine alternative actions to work towards resolution and to determine what can be done to address the situation. It is not uncommon for a complaint case, regardless of the determination, to include substantive assistance in facilitating communication between key parties and coordinating resources with the goal of addressing identified needs of the individual with disability.
As a result of the complaint process, ODSO staff routinely investigates and makes recommendations to the Department of Behavioral Health and Developmental Disabilities (DBHDD). However, not all complaints are related to DBHDD services. In fiscal year 2018-2019 thirty percent of complaints were unrelated to services provided by DBHDD or DBHDD contracted providers. (Figure 10).

FY 2018-2019 Complaint Outcomes

6 4 2 0
Complaint Outcomes
Substantiated
Inconclusive
Figure 9 & 10

Unsubstantiated Undetermined

Cases Involving Complaint Issues re:
Other 46% DBHDD Providers 46% State Hospitals 30%

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Assistance and Information Requests
Most citizens do not contact the Office of Disability Services Ombudsman (ODSO) to make a complaint about an agency or services' provider.4 Instead, they contact ODSO because they are having a problem and they need help or information so that it can be resolved. They are often frustrated by what they perceive as bureaucratic obstacles or by their lack of understanding or knowledge of a process or available resources. Therefore, ODSO intake staff spend a significant amount of effort coaching individuals; researching policies, procedures, regulations, and resources on their behalf; and facilitating communication between individuals and other agencies. Below are examples of the various ways that ODSO helped address 164 issues during the 2018 and 2019 fiscal years that stemmed from assistance and information requests:
Coordinated actions between a mental health consumer, a DBHDD regional office, and a DBHDD contracted provider to address organizational inefficiencies that resulted in a negative treatment experience with the provider. The provider acknowledged the consumer's experience was unacceptable and committed to address the issues raised;
Coordinated actions between DBHDD and a DBHDD contracted provider to address safety concerns of a consumer receiving supported housing services, resulting in the consumer being redirected to other appropriate supported housing options;
Communicated patient's safety concerns to a state psychiatric hospital patient advocate, resulting in the patient receiving a precautionary relocation to a different unit; and
Served as a liaison between DBHDD and a mother who requested a new review of level of need to determine if her child qualified for additional family supports while waiting to receive a Medicaid waiver.
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Most Frequent Issues: Assistance and Information Requests

Benefits

Top 5 Most Frequent Assistance Request Issues

Housing

Other

Care plan

Abuse and/or Neglect

Transportation

Subtotal (5 most frequent assistance request issues) Total (of all issues assistance requests)

FY 2018 and 2019
16 9 4 2 1 1 33 36

Percentage
44.0% 25.0% 11.0% .06% .03% .03% 92% of total 100%

Top 5 Most Frequent Information Request Issues
Benefits Discharge Other Housing Legal
Transportation
Subtotal (5 most frequent information request issues) Total (of all information requests issues)

FY 2018 and 2019
49 20 20 18 7 4 118 128

Percentage
38.0% 16.0% 12.5% 14.0% .10% .03% 92% of total 100%

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Medical Review Group (MRG)
The Governor appoints a Medical Review Group (MRG) to review all deaths of individuals with disabilities in state hospitals or state operated community residential services. The MRG consists of the ombudsman, who serves as the chairman, and four board certified physicians, one of whom must be a psychiatrist. Supported by O.C.G.A. 37-2-455, the medical review group makes four determinations as to whether:
1) the death was the result of natural causes or may have resulted from other than natural causes;
2) the death requires further investigation or review; 3) to make confidential recommendations to the ombudsman, the department, the division,
the state hospitals, and state operated community residential services regarding consumer treatment and care, policies, and procedures, which may assist in the prevention of deaths; and 4) to report to the appropriate law enforcement agency any suspected criminal activity or suspected abuse and shall report any suspected violation of any professional code of conduct to the appropriate licensing board.
5 The legislation that supports the Medical Review Group can be found in Appendix B.
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MRG Meetings
The MRG convened twice for the FY 2018-2019 to review the deaths that met the legislative guidelines. The MRG conducted two total reviews during the biennium. In all, a total of fifteen cases were reviewed.
Medical Review Statistics

Medical Review Dates
September 7, 2018 November 2, 2018 TOTAL

FY 2018 and FY 2019 Medical Reviews

New death cases reviewed

Cases w/follow up from previous meeting(s)

Cases Closed

Cases reviewed that are still pending

7

0

7

0

8

0

8

8

15

0

15

0

Total cases reviewed
7 8 15

Figure 13

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Policy, Regulatory, and Legislative Changes
Changes Implemented During the Biennium
1) Strategic Priorities Hospital to Community Partnership (Behavioral Health) DBHDD's crisis service system is a key component to the service array provided. Crisis services are offered through community partners, such as community service boards' crisis stabilization Community Quality Improvement Plan. The Georgia Crisis and Access Line, as well as DBHDD's state hospital system. DBHDD's director of behavioral health and medical director have teamed up to develop and implement a variety of initiatives that cross the community and state hospital system to create a more unified experience and better outcomes. Examples of this multi-pronged approach include policy alignment, enhancement of the discharge process to ensure coordination with aftercare providers and addressing a wide variety of challenges related to individuals transitioning to and from the community and hospital. Policy alignment is ongoing and needed changes have been identified and are being vetted with stakeholders. The discharge process has been analyzed, improvements proposed, and recommendations are currently being vetted with stakeholders.
2) Enterprise Crisis Plan There are multiple components to a comprehensive enterprise-wide crisis plan, and several quality improvement initiatives address these components. The High Utilizer Management (HUM) Program Development Project is serving this goal by identifying and investigating root causes of high use of crisis services and developing strategies to mitigate and address this concern. To date, a workflow has been created, job descriptions written and needed policy changes identified. This system will also collect information describing what barriers individuals are having trouble connecting to community services. This information will be used to make adjustments to the system to remove barriers and improve earlier access to community services. By reducing overuse of crisis resources, the capacity to serve those for whom the crisis system is intended is preserved and enhanced. Other initiatives supporting the efficient and appropriate use of crisis services include the Standardization of Admission and Exclusion Criteria across the DBHDD system. All community service boards, and state hospitals will use the same criteria to determine appropriate access and qualification for referral to the correct level of care. Hand in hand with this initiative has been the identification of Crisis Workflow Training needs. This training helps equip provider CSU/BHCC staff on the effective use of peers in crisis, diversion techniques, unit flow, engagement strategies, and developing successful partnerships with first responders.
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3) Best Practices in Providing Behavior Supports in the Community is a developmental disability initiative undertaken to disseminate best practice standards and facilitate skill development to those providers who render services to individuals with behavioral challenges. The initial response from providers has been very favorable, and additional topics and trainings are scheduled for Fall 2018. DBHDD is currently working with educators from Georgia State University to develop a certification process in applied behavior analysis designed to enhance the skills of existing behavior providers, attract, and increase the capacity of qualified providers of behavior supports working with people with intellectual and developmental disabilities.
17

Department of Behavioral Health and Developmental Disabilities Map of Service Regions
18

Appendix B Medical Review Group Legislation
O.C.G.A. 37-2-45. Medical review group to review the deaths of consumers
a) The Governor shall appoint a medical review group to conduct medical reviews of all deaths of consumers in state hospitals or state operated community residential services, which shall serve at the pleasure of the Governor. The medical review group shall consist of the ombudsman and four board certified physicians, one of whom shall be a psychiatrist. Three members of the medical review group shall constitute a quorum. The ombudsman shall serve as the chairperson and shall appoint a vice chairperson.
b) The physician members of the medical review group shall receive such compensation, if any, as may be fixed by the Governor. Such physician members shall be reimbursed for expenses incurred by them in performance of their duties such as transportation, lodging, and subsistence, at the same rate as members of the General Assembly.
c) The medical review group:
1) Shall be a review organization and shall conduct reviews of deaths of consumers in state hospitals and state operated community residential services as peer reviews pursuant to Article 6 of Chapter 7 of Title 31;
2) Shall review, within 60 days of notice of the death, all deaths of consumers:
A. Occurring on site of a state hospital or state operated community residential services providing services under this title;
B. In the company of staff of a state hospital or state operated community residential services providing services under this title; or
C. Occurring within two weeks following the consumer's discharge from a state hospital or state operated community residential services;
3) Shall have access to all clinical records of the consumer, all investigations conducted by the department, state hospitals, or state operated community residential services regarding the death, and all reviews of the death, including peer reviews;
4) May interview staff of the state hospitals and state operated community residential services, and other persons involved in the events immediately preceding and involving the death;
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5) Shall determine whether the death was the result of natural causes or may have resulted from other than natural causes;
6) Shall determine whether the death requires further investigation or review; 7) May make confidential recommendations to the ombudsman, the department, the
division, the state hospitals, and state operated community residential services regarding consumer treatment and care, policies, and procedures, which may assist in the prevention of deaths; and 8) Shall report to the appropriate law enforcement agency any suspected criminal activity or suspected abuse and shall report any suspected violation of any professional code of conduct to the appropriate licensing board. d) All peer review records submitted to or produced or created by the medical review group and the findings and recommendations of the medical review group, except for the quarterly reports, shall remain confidential and shall not be considered public records under Article 4 of Chapter 18 of Title 50.
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Appendix C Acronyms

BHCC CIT CMS CSH DAS/FSIU DBHDD DCA DCH DCH/HCF DHS DNR/DNI DOJ ECRH FY GBI GRHA GRHS HUD ME MOU MRG ODSO OPC NOW/COMP NWGRH PCH SAMHSA SWOT SWSH WCGRH

Behavioral Health Coordinating Council Crisis Intervention Training US Centers for Medicare and Medicaid Services Central State Hospital Division of Aging Services, Forensic Special Investigations Unit Department of Behavioral Health and Developmental Disabilities Department of Community Affairs Department of Community Health Department of Community Health, Healthcare Facility Regulation Department of Human Services Do Not Resuscitate/Do Not Intubate Department of Justice East Central Regional Hospital Fiscal Year Georgia Bureau of Investigations Georgia Regional Hospital at Atlanta Georgia Regional Hospital at Savannah U.S. Department of Housing and Urban Development Medical Examiner Memorandum of Understanding Medical Review Group Office of the Disability Services Ombudsman Olmstead Planning Committee New Options Waiver/Comprehensive Supports Waiver Northwest Georgia Regional Hospital Personal Care Home Substance Abuse and Mental Health Services Administration Strengths/Weaknesses/Opportunities/Threats Analysis Southwestern State Hospital West Central Georgia Regional Hospital

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