Follow-up review : Department of Human Resources, Autism Program

FOLLOW-UP REVIEW
Department of Human Resources
Autism Program January 2004

Russell W. Hinton, State Auditor

Performance Audit Operations Division 254 Washington St., S.W.

Department of Audits and Accounts

Atlanta, GA 30334-8400

This is a Follow-up Review of the Department of Human Resources Autism Program. The Department of Audits and Accounts released a Performance Audit on the Program in February 2001. This Follow-up Review was conducted to determine the extent to which the Program has addressed the recommendations presented in the report. A copy of the original report can be obtained through the contact information on the back of this Review.
Background Information
The Division of Mental Health, Developmental Disabilities, and Addictive Diseases (MHDDAD) within the Department of Human Resources provides funding for goods and services to assist persons with autism and their families. The Division was formerly known as Mental Health, Mental Retardation, and Substance Abuse (MHMRSA). It was officially restructured by a state law change effective July 1, 2002. This reorganization was effectively implemented by July 2003. The number of regions was also decreased from thirteen to seven to correspond with the seven state mental health hospitals.
Autism is defined as a lifelong developmental disability in which individuals may experience difficulty in language/communication, social development, and behavioral responses to their environment ... [It] occurs along a spectrum from mild to severe. Because the prevalence of autism is difficult to predict with certainty, the national estimates range from 0.2% to 0.6%. Using these percentages, it is estimated that the number of Georgians with autism ranges from approximately 16,400 to approximately 49,1001.

The Division allocates Autism Family Support funds to each of the seven MHDDAD regions who contract directly with providers for specific goods and services. For fiscal year 2004, the Division will provide a total of about $1.1 million in state funds to help persons with autism and their families. In accordance with DHR guidelines, the regions may use the funds to provide such goods and services as respite care; specialized equipment; medical, dental, and diagnostic services; counseling; and direct financial assistance.

1It should be noted that the original Performance Audit stated that autism occurs in 0.04% to 0.2%. The higher figures are due to an increase in the occurrence of autism. The cause for this increase is unknown.

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The Division also has a $267,500 contract with the Emory Autism Resource Center for autismrelated services such as providing information on the nature of autism, best practices in treatment, diagnostic assessments, and consultations to persons with autism and their families.
Autism Family Support funds are not the only assistance received by persons with autism. A diagnosis of autism is often accompanied by a diagnosis of mental retardation, making the person eligible for mental retardation services. The autism funds are reserved for those for whom other funded services are not available. As it is not possible to determine how many mental retardation dollars are spent on persons with autism, the Performance Audit focused only on Autism Family Support funds.
Synopsis of Audit Recommendations
The primary objective of the audit was to evaluate the extent to which the Program was meeting the needs of persons with autism and their families. The audit identified four areas in which actions needed to be taken to improve the program's delivery of services. These included developing a strategic plan, conducting a formal needs assessment, evaluating its contracts for appropriateness, and implementing controls over Family Support Funds.
Status of the Audit Recommendations
Recommendation in 2001: Action should be taken to develop a comprehensive strategic plan that addresses the needs of persons with autism and their families.
Current Status: This recommendation has not been implemented by DHR. According to Division staff, a strategic plan for the autism program will be the responsibility of the new Director of the Office of Developmental Diseases. There is currently a search to fill the position.

Recommendation in 2001: DHR should conduct a formal needs assessment concerning persons with autism and their families.
Current Status: This recommendation has been partially implemented. The Regions are currently performing autism-specific needs assessments for the next planning cycle (fiscal year 2006).
The Audit also noted that DHR could not assure that autism funds were distributed equitably. There is no evidence that the funding methodology has changed. Autism funds are allocated to providers based on the previous year's allocation. Changes in the contract amounts are driven by external factors, such as budget cuts, rather than regional population or determined need. It should be noted that additional autism family support funds made available due to a reallocation in fiscal year 2002 were allocated to the regions by population, as suggested in the report, but this ($201,323) represents only 18% of current Autism funds.
Based on the findings of the needs assessments, the program should consider developing plans to achieve a more equitable distribution of current autism funds, taking into account both the needs of those families already being served as well as the needs of any families either not being served or being under-served.

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In its response to the review, program management stated the following: The distribution methodology has changed since the initial allocation of autism family support funding. When additional funding for autism family support became available in [fiscal year 2002], the division used an allocation formula that left each region's initial "base" allocation intact, then distributed the additional funds based on each region's general population. Achieving absolute funding "equity" among the regions would require a reduction of funding from some regions in order to transfer additional funds to other regions. Such a transfer would inevitably result in some families, who already benefit from and rely on services, losing those services. While there may be isolated and extreme circumstances making that type of funding realignment necessary, we view such action as generally inappropriate. Rather than a complete redistribution of funding among the seven regions, we feel that it would be more appropriate to take into account various relevant factors including general population, estimated prevalence, needs assessment, and total existing funding.
It is our understanding that the Division is not prepared to adjust the base allocation for Autism Family Support funds, and will only make adjustments based on future additional funding increases. It is also our understanding that the Division does not track Family Support Funds on an individual family level.
However, our review indicates that the Division could calculate an allocation amount using factors such as general population, estimated prevalence, the needs assessment conducted by the Regions, and total existing funding. This base allocation could then be used as a starting point and as the need declines in one area, funds could be reallocated. Such a methodology would ensure funds were distributed among Georgians in an equitable manner.
Recommendation in 2001: DHR should reevaluate all of its autism-related contracts to ensure that the dollar amounts expended for contracts reflect the primary needs of persons with autism and their families.

Current Status: This recommendation has been implemented. The audit identified three specific issues to be addressed: the continued need for a respite care facility in Fayette County, evaluation of the contract with the Emory Autism Resource Center (EARC), and filling the vacant Autism Coordinator position.

The respite care facility was closed as recommended by the audit. Half of the funds ($201,323) were distributed to the regions based on population. The remaining funds were used to create a second contract with Emory University to provide further services and training at the regional level. The contract calls for services such as development of a "Train the Trainer" curriculum, community based training, and intensive week-long training sessions for families of those with autism.

Due to budgetary concerns, funds for the contract with the EARC were decreased in fiscal year 2004 and the deliverables listed in the contract were decreased accordingly. A review of the contracts during this review found that the core components of the contract remain despite the reduced funds.

The Autism Coordinator is no longer part of the Division structure. The duties formerly assigned to this position have been delegated to other staff and the funds are now used for consulting expenses.

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Recommendation in 2001: Action should be taken to implement more stringent controls over the expenditure of autism-related Family Support funds by the MHMRSA (now MHDDAD) regions.
Current Status: This recommendation has been partially implemented. The contracts continue to be maintained at the regional offices, not at the state office, and the regional staff are responsible for assuring that the contracted providers adhere to the procedures. However, the Division has changed its operating procedures to stress the need for stronger controls over autism funds. The procedures now require that the following information be maintained in the files:
Documentation that autism funds are funding of last resort; Documentation that funds are given on a sliding scale basis (documentation of family
income); Receipts of authorized and actual costs of services; A registry of approved service providers; and Payment information.
It should be noted that during the follow-up review, the Program agreed to have state-level staff conduct reviews of contract files to ensure that appropriate documentation is in place.

For additional information or to request a copy of the original report, please contact Paul E. Bernard, Director at 404-657-5220
or see our website: http://www.audits.state.ga.us/internet/pao.

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