Performance Audit: Department of Human Resources, Refugee Health Program

PERFORMANCE AUDIT DEPARTMENT OF HUMAN RESOURCES REFUGEE HEALTH PROGRAM
AUGUST 1999
PERFORMANCE AUDIT OPERATIONS DEPARTMENT OF AUDITS

TABLE OF CONTENTS
LETTER OF TRANSMITTAL ..................................................................i
EXECUTIVE SUMMARY.........................................................................ii
INTRODUCTION ......................................................................................1 Program Purpose and History ....................................................................1 Program Staffing .......................................................................................2 Health Screening Process ..........................................................................2 Activity Data.............................................................................................4 Financial Information ................................................................................6
AUDIT OBJECTIVES, SCOPE, AND METHODOLOGY....................6
FINDINGS AND RECOMMENDATIONS .........................................8-10
APPENDIX A: Refugee Arrivals by State, Federal Fiscal Year 1996.........11 APPENDIX B: Refugees by County of Resettlement and Country of Origin..................................................................................12

August 10, 1999

The Honorable Roy Barnes, Governor Members of the General Assembly Members of the Board of Human Resources The Honorable Audrey Horne, Commissioner Department of Human Resources
Ladies and Gentlemen:
This report provides the results of the performance audit of the Refugee Health Program. The audit was conducted as part of an ongoing program of performance auditing conducted by the Department of Audits under authority granted the State Auditor by OCGA 50-6-24. A copy of this report is filed as a permanent record with the State Auditor and is available to the public.
Appreciation is expressed to the staff of the Department of Human Resources and the Refugee Health Program for the cooperation and assistance provided during the audit.
Respectfully submitted,

RWH/bh

Russell W. Hinton State Auditor

Mission Statement The Department of Audits exists to provide decision-makers with credible management information to promote improvements in accountability and stewardship in state and local government.

EXECUTIVE SUMMARY
Performance Audit Refugee Health Program
August 1999
The Refugee Health Program, administered by the Department of Human Resources, is responsible for ensuring that refugees arriving in Georgia receive a health screening and complete any follow-up medical treatment prescribed as a result of the screening. The overall purpose of the Program is to eliminate health-related barriers to refugees' resettlement and to protect public health. Our review of the Program found that:

K The Program is not meeting its objective of ensuring that refugees are screened and
treated for medical conditions that could affect public health. As stated in a performance audit of the Program conducted in 1992, [the Program] lacks an effective follow-up system to ensure that refugees actually received their health screening and completed any prescribed treatment. We found that the Program did not have up-todate health screening information for 137 (34%) of a sample of 400 refugees who settled in Georgia in calendar year 1998. We also determined that the Program's database could not be used to verify that refugees found to have medical conditions such as tuberculosis, hepatitis B, syphilis, or parasitic infections had received follow-up
treatment as necessary. (Page 8, Finding No. 1)

K The Program also needs to take steps to ensure that the refugee information maintained
in its database is accurate and complete. We found that 7.5% (251) of the 3,344 refugee records in the Program's database were duplicate entries, were incomplete, or contained other errors. (Page 9, Finding No. 2)

K The Program should continue the efforts it had initiated prior to this performance audit
to improve its efficiency and effectiveness. Since the hiring of a full-time coordinator in June 1998, operational improvements have been made in the Program's procedures and staffing. The invoice form used by county health departments to report the results of the medical screenings has been modified and additional interpreter positions have been added to the Program's staff. (Page 10, Finding No. 3)

K Action should be taken to ensure that the dollar amount paid county health depart-
ments for conducting the refugee health screenings accurately reflects the health departments' actual cost of providing the services. Although the Program raised the reimbursement rate from $144 to a maximum of $225 effective October 1, 1998, it does not have any documentation regarding the actual cost of the health screenings or the follow-up medical treatment provided by the health departments. (Page 10, Finding No. 4)

Department of Audits

8/99

Refugee Health Program

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INTRODUCTION
Program Purpose and History
The Refugee Health Program is administered by the State Office of Primary Care within the Department of Human Resources' Division of Public Health. The overall purpose of the Program is to eliminate health-related barriers to refugees'effective resettlement in Georgia and to protect public health. The Program is responsible for ensuring that refugees receive a health screening to identify communicable diseases (such as tuberculosis) and other medical conditions (such as malnutrition) that may adversely impact effective resettlement. The Program is also responsible for ensuring that refugees complete any follow-up medical treatment prescribed as a result of the health screening.
The Department's Refugee Health Program and its Refugee Resettlement Program (administered by the Division of Family and Children Services) were established following the passage of the federal Refugee Act of 1980. As defined by the federal legislation, a refugee is
any person who is outside any country of such person's nationality or... outside any county in which such person last habitually resided, and who is unable or unwilling to return to, and is unable or unwilling to avail himself or herself of the protection of, that country because of persecution or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion, or in such special circumstances as the President [of the United States] after appropriate consultation may specify ...
Under the provisions of the Refugee Act of 1980, Georgia receives federal financial assistance to encourage effective refugee resettlement and promote refugees' economic self-sufficiency by providing such services as language training and employment services and by providing for the identification of refugees with medical conditions requiring treatment or observation. The Refugee Resettlement Program is responsible for encouraging refugees' effective resettlement and economic self-sufficiency and has a Memorandum of Agreement with the Refugee Health Program to provide for refugees'medical condition

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and treatment. The Memorandum of Agreement also specifies that the Refugee Health Program will provide interpreter services and health counseling for refugees.

While the Refugee Health Program is responsible for ensuring that refugees receive a medical screening and any follow-up treatment, the county health departments are responsible for actually conducting the screenings and providing the follow-up treatment. Using federal funds, the Program pays the health departments a maximum of $225 (depending on the number of diagnostic tests conducted) for each screening that is conducted within 90 days of the refugee's arrival in the U.S. The health departments may obtain Medicaid reimbursement for the cost of screenings completed outside the 90-day window and the cost of any follow-up treatment. (Refugees who are financially needy are Medicaid-eligible during the first eight months following resettlement in the U.S.)

Program Staffing
The Program is administered by a 14-person staff composed of a Program coordinator, an administrative assistant, a statistical analyst, and 11 interpreters (two of whom are part-time). The interpreters work primarily at county health departments to assist refugees as they move through the process. It should be noted that the Program's current coordinator was hired in June 1998; prior to this date, the position was filled by an interim director for about two years.

Health Screening Process
As shown by Exhibit 1 on the following page, the health screening process begins prior to the refugees'arrival in Georgia. An overseas medical exam is conducted before they enter the U.S. to identify any medical conditions or diseases that would exclude them from entering the country. Persons having such diseases as infectious leprosy and HIV/AIDS or having specific mental defects are excluded by federal regulations from resettling in the U.S. The health status of refugees is also checked when they initially enter the country at one of the eight quarantine stations (located in major airports) operated by the Centers for Disease Control.

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Refugee completes overseas medical
exam

Exhibit 1 SCREENING PROCESS

Excludable

conditions identified?

Refugee refused Yes admittance to U.S.

A

No
Refugee proceeds to quarantine station

County health department
contacts refugee and conducts
health screening

Obvious health concerns
noted?

Refugee refused
Yes
admittance to U.S.

Medical results and arrival information
sent to Program
Program date stamps, reviews,
and confirms arrival information
Information is sent to appropriate county health department and entered into database
A

Screened within 90 days of U.S. arrival?

All necessary follow-up treatment conducted

Yes
Reimbursement request sent to
Program

No
Cost of screening billed
to Medicaid

Screening results sent to
Program

Treatment information
sent to Program

Information entered into Program's tracking
system

Source: Federal Office of Refugee Resettlement and Georgia Refugee Health Program

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Prior to a refugee locating in Georgia, the Refugee Health Program receives a copy of the overseas medical exam and other arrival information (including the refugee's name, county destination, and sponsor's name) from the quarantine station. This information is reviewed by the Program, entered into their data tracking system, and forwarded to the appropriate county health department. The county health department is then responsible for contacting the refugee to schedule the health screening.

The health screening consists of: tests for tuberculosis, hepatitis B, parasitic infections, sexually transmitted diseases; a review of immunization records; tests for diabetes, anemia, and malnutrition; vision and hearing tests; a dental assessment; and a pregnancy test, if applicable. Vaccinations (immunizations) are provided as necessary, and refugees are offered an HIV test.

After conducting the screenings, the county health departments submit invoices to the Program that show the results of the screening and indicate whether follow-up medical care is recommended. It should be noted that the results of HIV tests are not included on the screening invoice due to confidentiality concerns. County health departments are also instructed to inform the Program when follow-up treatment is completed.

Activity Data
Records maintained by the Refugee Health Program indicate that 3,342 refugees arrived in Georgia during calendar year 1998. In federal fiscal year 1996 (the most recent year for which data is available), Georgia ranked seventh in the number of refugees received by state (see Appendix A). The six states that had more refugees than Georgia were California, New York, Washington, Florida, Texas, and Illinois.

As shown by Exhibit 2 on the following page, the 3,342 refugees who settled in Georgia in calendar year 1998 located in 33 counties in different parts of the state. Most of the refugees (84%) located in DeKalb County (1,886), Fulton County (640), and Gwinnett County (268). The refugees came from 15 countries, with 51% (1,697) from Bosnia and 30% (1,014) from Vietnam. More complete information regarding the refugees' countries of origin and the counties in which they located is presented in Appendix B.

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Exhibit 2 DISTRIBUTION OF REFUGEES BY COUNTY
CALENDAR YEAR 1998

3

4

1

4

96

5

26

149

268 4

1,886

2

11 640 66

28 1

18

1

3

1 1

5

1
90 10

# of Refugees per County 1-50
51-100 101-500 501-1,000 Over 1,000
12

2

6

2

1

4

Source: Refugee Health Program Records

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Financial Information
The Program is funded entirely with federal funds provided by the Office of Refugee Resettlement in the U.S. Department of Health and Human Services. One federal grant comes directly to the Program and is used to fund the Program coordinator and statistical analyst positions and related expenses. Grant funds are also received by the Refugee Resettlement Program in the Division of Family and Children Services and are made available to the Program through a Memorandum of Agreement. These funds are used to fund the Program's administrative assistant and interpreter positions and associated travel and regular operating expenses, contractual expenses for additional interpreter services, and the cost of reimbursing the county health departments for the health screenings.
In state fiscal years 1998 and 1999, the Program's expenditures totaled $710,406 and $718,225, respectively. The Program's fiscal year 1999 expenditures have been impacted by the increase in the reimbursement amount paid to county health departments for completing the health screenings and from filling the Program coordinator and statistical analyst positions that had been vacant.
Prior to October 1, 1998, the Program paid the county health departments $84 for each health screening they conducted and paid the state public health laboratory $60 for the lab work involved in each health screening. For federal fiscal year 1999 (beginning October 1, 1998), the Program raised the reimbursement rate to a maximum of $225 (depending on the number of diagnostic tests conducted) with the health departments responsible for the cost of any lab work. Exhibit 3 on the following page shows the Program's expenditures for fiscal years 1998 and 1999.

AUDIT OBJECTIVES, SCOPE, AND METHODOLOGY
The primary objective of this audit was to determine if the Program has implemented internal controls for ensuring that all refugees locating in Georgia receive a health screening and follow-up medical treatment as necessary.

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Exhibit 3 FUND SOURCES AND EXPENDITURES
FISCAL YEARS 1998 AND 1999

FUND SOURCE Federal Grants

FISCAL YEAR

1998

1999

ACTUAL ACTUAL (1)

$710,406

$718,225

EXPENDITURES Personal Services Regular Operating Travel Equipment Per Diem, Fees and Contracts Computer Charges Telecommunications

TOTAL

$260,840 418,166
8,024 0
20,444 2,932
0 $710,406

(1) Unaudited figures

Source: FACS Reports and Program Records

$350,518 312,471
8,649 8,534 38,051
0 2 $718,225

The audit was conducted in accordance with generally accepted government auditing standards for performance audits and focused on fiscal years 1998 and 1999. The audit methodology included reviews of Program files and records, interviews with Program staff, and a review of the Program's database of incoming refugees which includes screening and follow-up information.
This report has been discussed with appropriate personnel representing the Program and the Department of Human Resources. A draft copy was also provided for their review and comment. Pertinent responses received from the Department, including plans for corrective action, have been included in the report as appropriate.

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FINDINGS AND RECOMMENDATIONS
Finding No. 1
The Refugee Health Program is not meeting its objective of ensuring that refugees are screened and treated for medical conditions that could affect public health. Although the Program has taken steps to improve its operations, the Program still lacks an effective follow-up system to ensure that refugees actually received their health screening and completed any prescribed treatment (as stated in a previous performance audit of the Program conducted in 1992). The need for the Program to develop a more effective system for ensuring that refugees receive a medical screening and appropriate follow-up treatment is discussed in the following paragraphs.
(A) The Program does not maintain the information necessary to meet its stated objective of ensur[ing] that 90-95% of newly arriving refugees in Georgia receive a health assessment/screening. Of a statistically valid sample of 400 refugees who settled in Georgia in calendar year 1998, information was available for only 263 refugees (66%), of whom 247 had been screened and 16 had not been screened. No information was available on the Program's database for 137 (34%) of the 400 refugees included in the sample.
It should be noted that to determine if these refugees had actually been screened by the county health departments, the audit team contacted health department personnel in 17 counties. Of the 137 refugees for whom the Program had no information, the audit team determined that 103 had been screened and three had not been screened; no information was found for 31 of the refugees.

(B) The Program does not maintain sufficient follow-up information to meet its objective of ensur[ing] that 90% of the refugees...[with] conditions of public health concern are further evaluated and provided treatment if needed. The Program's database cannot be used to verify that refugees found to have medical conditions such as tuberculosis, hepatitis B, syphilis and other sexually transmitted diseases, or parasitic infections received follow-up medical treatment as necessary. For example, of the 247 refugees included in the audit sample who received screening, 10 had abnormal chest x-rays after testing positive for TB; per the Program's database, however, only one of these persons completed follow-up medical

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treatment. Similarly, no treatment information was available to determine if the 19 persons who tested positive for hepatitis B had received the necessary medical treatment.
As recommended in the 1992 performance audit of the Refugee Health Program, action should be taken to implement a more effective system for verifying that refugees are screened and receive any prescribed medical treatment as required. Program personnel should contact county health departments when information is not received within 90 days of a refugee's arrival indicating that the refugee has received a medical screening. Similarly, the Program should maintain documentation to verify that refugees found to need medical treatment actually complete the prescribed course of treatment. Implementation of this recommendation would enable the Program to meet its overall purpose of eliminating health-related barriers to refugees'effective resettlement and protecting public health.

Finding No.2
The Program should take steps to ensure that the refugee information maintained in its database is accurate and complete. The Program's database that contains all of the Program's records regarding refugee screening and treatment information does not include the controls necessary to identify and prevent data entry errors. Reviews of the database conducted to develop the audit sample cited in Finding No. 1 identified multiple errors and incomplete records. Of the 3,344 refugee records for calendar year 1998, 251 (7.5%) were duplicate entries (refugee name and/or alien number), were incomplete, or contained other errors. In 151 cases, for example, duplicate entries had been made to the database, resulting in two or more records for the same refugee.
Prior to the release of this report, Program staff indicated they were already aware of the need to improve the data entry process and the accuracy of the database. It should be noted that one of the county health departments visited during this audit is in the process of implementing its own database system for tracking the screening and treatment of refugees. Health department personnel indicated that the system will not allow for duplicate entries (by name or alien number); will flag records for refugees that do not have screening information within 90 days of their arrival date; and will flag the records of refugees referred for follow-up treatment.

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Finding No. 3
The Program should continue the efforts it had initiated prior to this performance audit to improve its efficiency and effectiveness. Since the hiring of a full-time Program coordinator in June 1998, operational improvements have been made in the Program's procedures and staffing. The invoice form used by county health departments to report the results of the medical screenings has been modified to eliminate the need to wait until follow-up treatment is completed to submit the form to the Program. This improvement should result in the Program receiving the screening results in a more timely manner. It should be noted that counties have been instructed to separately report any follow-up treatment.
The Program has taken steps to improve the screening process by adding two additional interpreter positions. This action should assist county health departments in working with refugees and in educating them regarding the U.S. health care system.

Finding No. 4
The Program should take steps to ensure that the dollar amount paid county health departments for refugee health screenings accurately reflects the health departments'actual cost of providing the services. Although the Program raised the reimbursement rate from $144 to a maximum of $225 effective October 1, 1998, it does not have any documentation regarding the actual cost of the health screenings or the follow-up medical treatment provided by the health departments. Department personnel indicated that the decision to increase the reimbursement rate was based on an informal survey of other states' reimbursement rates.
The Program should ensure that the reimbursement rate is in line with the costs incurred by the health departments in conducting the screenings and providing any follow-up services. By obtaining cost data on a periodic basis, the Program could adjust the reimbursement rate as necessary to ensure that county health departments do not lose money on the screenings.

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Appendix A

REFUGEE ARRIVALS BY STATE -FEDERAL FISCAL YEAR 1996

California

13,482

New York

12,464

Washington

4,247

Florida

3,646

Texas

3,636

Illinois

3,328

Georgia

2,504

Pennsylvania

2,488

Massachusetts

2,325

Michigan

2,167

Minnesota

2,056

Missouri

1,871

Virginia

1,616

Arizona

1,541

Oregon

1,367

Ohio

1,350

New Jersey

1,267

Kentucky

1,053

Maryland

1,034

Colorado

1,024

Tennessee

984

Iowa

975

North Carolina

966

Utah

780

Wisconsin

734

District of Columbia

655

Connecticut

636

Nebraska

474

Kansas

473

Idaho

415

Louisiana

409

Indiana

352

North Dakota

341

South Dakota

287

Vermont

259

New Hampshire

215

Nevada

206

Oklahoma

202

New Mexico

166

Maine

152

Alabama

149

Rhode Island

99

Hawaii

83

South Carolina

78

Arkansas

69

Montana

59

Alaska

45

Mississippi

19

Delaware

17

West Virginia

12

TOTAL

74,777

Source: Department of Health and Human Services, Office of Refugee Resettlement

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Appendix B is an attached file.

Locations