Performance Audit Report No. 12-08

June 2013

Georgia Department of Audits and Accounts
Performance Audit Division
Greg S. Griffin, State Auditor Leslie McGuire, Director

Why we did this review
This review of the Roosevelt Warm Springs Institute for Rehabilitation (the Institute) was conducted at the request of the House Appropriations Committee. The Committee asked that we examine the efficacy of Institute programs and the use of its facilities. As a result, we reviewed 1) whether the Medical Rehabilitation Unit is self-sustaining, 2) the effectiveness of the Vocational Rehabilitation Unit, 3) facility utilization and management, and 4) whether auxiliary programs are selfsustaining.
About the Institute
The Institute is a state-operated comprehensive rehabilitation center. In fiscal year 2012, it expended $39 million, primarily in support of its medical and vocational units. In fiscal year 2011, the medical unit provided inpatient and outpatient medical services to approximately 2,200 patients, and the vocational unit provided residential vocational training to approximately 300 individuals with disabilities. Its 940acre campus also includes over 30 historical cottages, a camp, conference center, recreation center, and golf course. During the period of our review, the Institute was overseen by the Georgia Department of Labor. The program was transferred to the newly created Georgia Vocational Rehabilitation Agency on July 1, 2012.

Roosevelt Warm Springs Institute for
Rehabilitation
Action needed to ensure Institute's
financial viability and effectiveness
What we found The Institute's core activities face a number of strategic and operational challenges. Specifically, the Institute operates a Medical Rehabilitation Unit open to the general public that incurs annual financial losses. The employment and independent living outcomes of its residential vocational rehabilitation program have not been tracked, monitored, or used to evaluate the program. In addition, many of the facilities on the historic Institute campus are run-down or in disrepair, with repairs estimated at over $10.1 million.
Medical Rehabilitation Unit The majority of the Institute's state appropriations have been used to cover patient revenue shortfalls in its Medical Rehabilitation Unit. As a result, the state is effectively subsidizing the medical care for the general public treated at the medical facility. In fiscal years 2011 and 2012 the medical unit would have incurred losses of $1.5 million and $755,000, respectively, without state appropriations. In its amended fiscal year 2013 budget, an additional $5 million in state funds was appropriated to cover expected revenue shortages in the medical unit. A key factor in the operating deficit is low utilization rates. Geographic location and competition from other providers contribute to the low utilization rates.
If the Institute directed the state funds from the medical unit to the Vocational Rehabilitation Unit, the state would be eligible for additional federal funding. For example, $3.4 of the Institute's $5.4 million state appropriation was used to cover the medical unit's losses in fiscal year 2011. If these funds were used for vocational rehabilitation costs, the state would have been eligible

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for an additional $12.9 million in matching federal funds.
Vocational Rehabilitation Unit The Institute operates a residential vocational training program to prepare individuals with disabilities for employment. However, it does not track students' rate of employment after discharge. In addition, the Institute has no outcome measures related to students' increased capacity to live independently, which is a secondary objective of the vocational program. As a result, the Institute cannot demonstrate the effectiveness of the residential vocational program.
While the Institute tracks vocational program completion rates as a primary performance measure, the decisions to graduate students from the program as "Work Ready" are not based on a standardized determination process. We found no evidence that a Work Ready disposition is determined using consistent criteria prior to discharge. Additionally, Institute policies do not indicate a method for how work readiness will be determined or include a standard form to document the determination. Instead, work readiness appears to be based on staff's general observations of a student's work habits.
Facilities Of the 72 buildings on the Institute's campus, 17 are unusable due to their deteriorated condition. In addition to these buildings, several inhabitable buildings require renovations and repairs, some of which are extensive. Known costs total an estimated $10.1 million; however, cost estimates to renovate, repair, or demolish some buildings have not been determined, which would further increase this estimate.
What we recommend
Medical Rehabilitation Unit The General Assembly and the Georgia Vocational Rehabilitation Agency (GVRA) should review the long-term viability of the Institute's medical unit. If the medical unit remains open, the General Assembly should determine the extent to which it will continue to subsidize the medical operations. An evaluation is needed to determine whether any proposed options to improve the medical unit's financial circumstances would generate the revenue necessary to meet the desired level of profitability on a longterm basis.
Vocational Rehabilitation Unit To monitor program effectiveness, the Institute should implement a process to analyze the employment and independent living outcomes of its vocational student population after discharge. To ensure students' preparation for employment is properly assessed prior to discharge, the Institute should clearly define completion criteria and standardize the method used to determine and document students' readiness to enter the workforce.
Facilities The Institute should create a master facility plan that includes future plans and costs for its uninhabitable and deteriorating buildings. Staff should identify potential uses for its buildings to justify the investment needed to renovate, repair, or maintain the buildings. In addition, the General Assembly should decide how to pay for the required investment.
GVRA Response: After a thorough review of the draft performance audit, we agree this is a fair assessment of Roosevelt Warm Springs (Institute) operations. Effective July 1, 2013, the Institute will enter into an interagency agreement with Georgia Regents University to manage the hospitals to enhance the delivery of care at its rehabilitation and acute care hospitals. In addition, over the past year, the Institute has initiated a transformation of its vocational services to specifically focus on measurable employment and independent living outcomes.

Roosevelt Warm Springs Institute for Rehabilitation

i

Table of Contents

Purpose of the Audit

1

Background

1

Institute Overview

1

History and Description

1

Organizational Structure

3

Medical Rehabilitation Unit

4

Vocational Rehabilitation Unit

5

Auxiliary Programs

8

Financial Data

9

Development Fund

11

Other States

11

Findings and Recommendations

12

The practice of using state appropriations to subsidize the Institute's Medical

Rehabilitation Unit is questionable and has impacted the state's ability to maximize

federal vocational rehabilitation funds.

12

The Institute does not track the outcomes of its vocational students to determine

how well it is meeting program objectives of preparing students for employment and

independent living.

17

The Institute should develop consistent, measureable assessment criteria to

determine when students have successfully completed the vocational program and a

performance goal for a reasonable level of vocational services after discharge.

19

The Institute should evaluate the effectiveness of individual vocational services and

admission criteria.

22

Several buildings on the Institute's campus have deteriorated to the point of

requiring extensive renovation, repair, or demolition.

24

The Institute should monitor the profitability of each of its revenue-generating

activities on an on-going basis.

28

Appendix A: Objectives, Scope, and Methodology

30

Appendix B: State Comprehensive Rehabilitation Centers

33

Appendix C: Distribution of Patient Admissions

34

Appendix D: Skills Training Programs

36

Roosevelt Warm Springs Institute for Rehabilitation

ii

Roosevelt Warm Springs Institute for Rehabilitation

1

Purpose of the Audit
This review of the Roosevelt Warm Springs Institute for Rehabilitation was conducted at the request of the House Appropriations Committee. The Committee requested we review the efficacy of Institute programs and the use of its facilities. Specifically, the audit objectives were to determine:
1. whether the Medical Rehabilitation Unit is self-sustaining; 2. the extent to which the residential Vocational Rehabilitation Unit prepares
students for employment and independent living; 3. the extent of facility utilization and management; and 4. whether auxiliary programs are self-sustaining.
This audit generally covered Institute activity during fiscal years 2009 to 2012 with consideration of earlier or later periods when relevant. During this time, the Institute was overseen by the Georgia Department of Labor (GDOL). On July 1, 2012, the Institute was transferred to the newly created Georgia Vocational Rehabilitation Agency (GVRA). A detailed description of the objectives, scope, and methodology used in this review is included in Appendix A. A draft of the report was provided to GVRA and GDOL for their review, and pertinent responses were incorporated into the report.
Background

Comprehensive rehabilitation centers are residential centers that provide training,
counseling, and medical support to
individuals with disabilities

Institute Overview
The Roosevelt Warm Springs Institute for Rehabilitation (the Institute), in Warm Springs, Georgia, is a comprehensive rehabilitation center. The Institute prepares individuals with disabilities for employment in a 24-hour residential setting. Also, the Institute provides inpatient rehabilitation, long-term acute care, and outpatient medical services. Its mission is "to empower individuals with disabilities to achieve personal independence."
History and Description
During the 1920s, Franklin D. Roosevelt began visiting Warm Springs, Georgia, to treat his polio by soaking in the warm springs. Roosevelt purchased the property in 1926 to develop a polio treatment center, which was managed by the Georgia Warm Springs Foundation. With the release of the polio vaccine in 1955, the center gradually focused on rehabilitation for all types of disabilities. In 1964, the state opened a vocational rehabilitation facility on property donated by the foundation, and 10 years later, the hospital and remaining property were transferred to the state. A condition of this transaction required the state to use the property for public purposes for 99 years. The medical and vocational programs were later merged and became known as the Roosevelt Warm Springs Institute for Rehabilitation.

Roosevelt Warm Springs Institute for Rehabilitation

2

The Institute has a 940-acre campus with 72 buildings.1 As shown in Exhibit 1, the campus includes an inpatient hospital building, an outpatient clinic, conference center auditorium and lodging, two dormitories, a recreation center, a golf course, campgrounds, 31 historic cottages, and dining facilities. The entire campus was designated a National Historic Landmark District in 1980. It should be noted that Roosevelt's Little White House is managed by the Georgia Department of Natural Resources and is not part of the Institute's campus.
Exhibit 1 Satellite View of the Institute's 940-Acre Campus

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Source: Bing Maps and Institute campus map
1 As points of comparison, the University of North Georgia (Dahlonega) campus covers 630 acres with 69 buildings including the main campus and nearby parks and forests, and the University of Georgia's main campus covers 605 acres and includes 313 buildings.

Roosevelt Warm Springs Institute for Rehabilitation

3

Organizational Structure Currently, the Institute is part of the Georgia Vocational Rehabilitation Agency (GVRA). In March 2012, the General Assembly passed House Bill 1146, which moved the Division of Rehabilitation Services (including the Institute) from the Department of Labor to the newly created GVRA. The new agency is administratively attached to the Department of Human Services (DHS).
As shown in Exhibit 2, the Institute employs approximately 481 employees, most of whom work in the Medical Rehabilitation and Vocational Rehabilitation Units. In addition, the Institute provides auxiliary services such as a conference center and a camp. The campus employs staff to operate and manage the Institute in the areas of facilities, financial, information technology, and human resources.
Exhibit 2 Core Services and Number of Positions

Georgia Vocational Rehabilitation Agency

Roosevelt Warm Springs Institute for Rehabilitation Executive Director's Office
4 employees

Medical Rehabilitation Unit Includes Inpatient Rehabilitation Facility, Long Term Acute Care Hospital, & Outpatient Services
238 employees

Vocational Rehabilitation Unit Includes Employment Development,
Independent Living, Enterprise Services, & Therapeutic Recreation (Camp Dream & Recreation Center)
112 employees

Facility Services Includes Maintenance, Housekeeping, Grounds,
Facility Police, Risk Mgmt, & Transportation

Fiscal Services Includes the Business Office, Accounting, &
Materials Mgmt

77 employees

26 employees

Source: Institute records as of March 2012

Human Resources Includes Human
Resources Office & Staff Development
(Conference Center & Information Center)
17 employees

Management Information Includes Information Technology & Medical
Records
7 employees

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4

Medical Rehabilitation Unit The Institute operates a state-run medical facility that provides inpatient and outpatient care to the general public.2 Two specialty hospitals operate out of a single inpatient building on the Institute's campus. Outpatient services are offered on the main Warm Springs campus and in two off-campus clinics. It is important to note that the medical and vocational units serve distinct populations, as the medical unit primarily serves the general public, while the vocational unit typically serves clients of Georgia's Vocational Rehabilitation program.
Inpatient Services Inpatient services comprise an Inpatient Rehabilitation Facility (IRF) and a Long Term Acute Care Hospital (LTACH).
IRF Provides rehabilitative services such as physical, occupational, speech, and recreation therapies, such as those needed by stroke patients. The IRF provides less intensive care than the acute care hospitals from which it receives referrals. The IRF has 52 licensed beds. In fiscal year 2011, there were 449 admissions to the IRF, and the average length of stay was 14 days.
LTACH Provides many services offered at acute care hospitals, with the primary difference being a longer length of stay. Internal medicine physicians direct a patient's care, which may include wound care, pain management, respiratory therapy, and/or dialysis. LTACH patients may also undergo physical, occupational, and speech therapies. The LTACH has 32 licensed beds. In fiscal year 2011, there were 150 admissions to the LTACH, and the average length of stay was 27 days.
Outpatient Services Outpatient services include clinics in Warm Springs, LaGrange, and Newnan.
Warm Springs Physical, occupational, and speech therapies are available at the Warm Springs outpatient clinic. Also, diabetic and other foot-related services are offered by a podiatrist twice a week. Cardiology, nephrology, and post-polio services are offered part-time. In addition, vocational students receive some medical, therapeutic, and psychiatric services in the Warm Springs outpatient clinic. The Warm Springs clinic provided 6,344 services to patients in fiscal year 2011.
LaGrange Physical therapy is available at the LaGrange clinic five days a week. In fiscal year 2011, 3,323 services were provided to patients in the LaGrange clinic.
Newnan A podiatrist travels to Newnan to provide diabetic and other foot-related services for a half-day, three times a week. Patients received 1,234 services at the Newnan clinic in fiscal year 2011.

2 The medical unit holds hospital and home care accreditations from the Joint Commission on Accreditation of Healthcare Organizations.

Roosevelt Warm Springs Institute for Rehabilitation

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A Rehabilitation Technology and Durable Medical Equipment program is also available at the Institute. This program sells and services wheelchairs, custom crutches for polio survivors, and custom shoes for diabetics.
Vocational Rehabilitation Unit
The vocational unit is a residential program that provides training, counseling, and medical support to individuals with disabilities to prepare them for employment and independent living.3 In fiscal year 2011, the program admitted 204 students. Most students are between the ages of 18 and 22, and students completing the program have an average length of stay of seven to ten months. Vocational students have a variety of disabilities, including both mental and physical impairments. As shown in Exhibit 3, a significant percentage of the program's students have disabilities such as Mild Intellectual Disability, Attention Deficit Hyperactivity Disorder (ADHD), and learning disabilities. Some students have multiple disabilities. According to GVRA, students with more than one disability typically have more functional limitations and benefit from more intensive vocational training provided in a residential setting as opposed to services provided in the community.
Exhibit 3 Types of Disabilities1 Students Discharged in Fiscal Years 2009-2011

Mild Intellectual Disability2

42%

ADHD

14%

Learning Disability

12%

Pervasive Developmental Disorder Spectrum3

10%

Brain Injury/Cognitive Disorder

8%

Cerebral Palsy

7%

Borderline Intellectual Functioning

5%

Visual Impairment

2%

Seizure Disorder

2%

Spina Bifida 2%

Mood Disorder 1%

Anxiety Disorder 1% Moderate Intellectual Disability2 1%

Other or Unknown

7%

1Some students have more than one disability, so percentages will not total to 100%. 2Mild Intellectual Disability is generally defined as having an IQ between 50 and 70 and Moderate Intellectual
Disability as an IQ between 35 and 49. 3Pervasive Developmental Disorder Spectrum includes Autism and Asperger's Disorder.

Source: Institute records

3 The vocational unit holds accreditations in Comprehensive Vocational Evaluation Services and Employee Development Services from the Commission on Accreditation of Rehabilitation Facilities.

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Most students live on campus in the dormitory in Exhibit 4. This dormitory was opened in October 2011, replacing the Institute's nearly 50-year-old dormitory. The new 150-bed dormitory has both apartment- and dorm-style rooms.
Exhibit 4 New Dormitory for Vocational Students

Source: Photograph provided by Roosevelt Warm Springs Institute for Rehabilitation
Vocational Services Students are most often referred to the Institute by a field counselor in GVRA's Vocational Rehabilitation (VR) program. Admissions staff evaluates the applicant's suitability for the program, which includes a review of medical, behavioral, and mobility issues. Upon enrollment in the vocational program, each student is assigned a team that includes a behavior specialist, a vocational coordinator, an independent living coordinator, and potentially an academic coordinator. The student's case is managed by a certified rehabilitation counselor who oversees the team. Most students follow a "Work Ready" track to prepare them for employment. However, some students focus on an academic goal, such as obtaining a SAT score high enough to enter college, and are discharged as "School Ready."4 Exhibit 5 illustrates the typical service plan for a student on the Work Ready track. Additional services (e.g., academic education, driver education) may also be provided based on the student's needs and interests.
4 Of the 135 students who graduated in fiscal year 2011, nine were discharged as "School Ready" while the remaining 126 students were discharged as "Work Ready."

Roosevelt Warm Springs Institute for Rehabilitation

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Exhibit 5 Typical Plan for Student on Work Ready Track1
Orientation (1 week)

Independent Living (1 month) Classes include grooming and hygiene, communication, money management, etc.
Behavioral Management (2 months) Classes include interpersonal skills, problem
solving, and work behaviors.

Production Support Workshop (4-6 weeks) Staff assess work habits in an on-campus
production site to determine when a student is ready for external work experiences.
Work Adjustment Training (varies) Student is placed in a work site on the Institute's campus or at a local business to develop acceptable work habits and behaviors. Most students have 2 to 3 work placements,
which total 200 to 400 hours.

Occupational Skills Training (varies) Classes teach skills in specific vocations
(e.g., certified nursing assistant, customer service).

Employment Readiness Training (1-2 weeks) Classes assist with resume writing and employability skills.

Discharge Student returns to the community and works
with VR staff to obtain employment.
1Exhibit represents a student's typical work plan during the audit review period. In fiscal year 2014, this plan will no longer be universally applied. Program plans will be based on individual needs, and admissions processes will allow direct entry into career and technical education and individualized support services.
Source: Interviews with vocational staff and review of student files

Relationship with the Vocational Rehabilitation Program
Most students are clients of GVRA's VR program and have been referred by their VR field counselors. The VR program provides services to eligible individuals with disabilities throughout the state to help them prepare for, locate, and retain employment. Services such as career exploration and on-the-job training may be provided by VR staff, nonprofit community rehabilitation programs, or other vendors. Work adjustment training and some other services provided by the Institute's residential program are also provided by the VR program in the community. However, some services, such as independent living training, are not

Roosevelt Warm Springs Institute for Rehabilitation

8

readily available in all parts of the state. In addition, Institute staff indicated that the full-time, residential nature of the Institute's vocational program allows students to experience independence, learn interpersonal skills, and prepare for full-time employment.
After completion of the Institute's vocational program, the student returns home and continues to work with the referring field counselor. Additional training and other services may be provided as needed. A VR employment specialist will help the student locate employment. When the student achieves 90 days of employment in a suitable position, the VR case is closed, and the client is considered rehabilitated. Employment outcomes are tracked by VR in Georgia Rehabilitation Online Works (GROW). However, the Institute did not obtain access to employment outcomes in GROW until the summer of 2012.
Auxiliary Programs
The Institute operates a recreation center, camp, conference center, and golf course available to vocational students, medical patients, and the general public. Pictures of facilities used by these programs are shown in Exhibit 6.
Recreation Center: The Frank C. Ruzycki Center for Therapeutic Recreation is a fully accessible recreation center opened in 1996. It primarily serves vocational students but is also open to medical patients and to community members, who can purchase memberships for a nominal fee. The recreation center's amenities include a swimming pool, basketball court, bowling alley, track, weight room, and racquetball courts. The center had over 39,000 visits in fiscal year 2011.
Camp Dream: Camp Dream is a 74-acre camp that opened in 1996. It primarily provides recreational experiences to persons with disabilities. The Institute partners with organizations, such as Camp Twin Lakes, that rent the camp for summer activities. The cost to rent is $30 per person, per night, which includes the use of two lodges, a dining hall, the Center for Therapeutic Recreation, a nature trail, a lake, a pool, and sports and social activities. The renting organization staffs the camp and arranges for food services with the onsite food vendor for an additional fee. Although available for rental year-round, summer is the camp's busiest season, when it hosts week-long camps. In fiscal year 2011, Camp Dream hosted 12 camps and 18 other events.
Conference Center: Accommodations and meeting facilities are available for private events through the Roosevelt Warm Springs Conference and Continuing Education Center. Two auditoriums, fully equipped classrooms, and other meeting spaces are available. There were over 130 conference center events held in fiscal year 2011. In addition, on-campus lodging is available for individuals and groups utilizing the conference center, as well as families of students and patients.
Golf Course: The 9-hole public Roosevelt Memorial Golf Course was founded in 1926. It was closed in March 2011 due to a funding shortage. Institute staff have indicated it may be reopened soon, but no official

Roosevelt Warm Springs Institute for Rehabilitation

9

opening date has been set. Prior to its closure, a private contractor operated the course, and annual community memberships were available.
Exhibit 6 Auxiliary Program Facilities

Center for Therapeutic Recreation

Camp Dream

Conference Center Auditorium

Golf Course

Source: Photographs provided by Roosevelt Warm Springs Institute for Rehabilitation or taken by audit team

Financial Data
Exhibit 7 summarizes Institute revenue and expenditures for fiscal years 2010-2013. Expenditures totaled approximately $39 million in fiscal year 2012. Of the Institute's total fiscal year 2012 revenues, approximately 48% came from agency-generated income, 38% came from federal funds, and the remaining 14% came from state funds. The majority of state funds were used to subsidize the operations of the medical unit. For fiscal year 2013, the Institute is projected to expend $33 million. To cover expected funding shortages in the medical unit, an additional $5 million in state funds was added to the Institute's amended fiscal year 2013 budget. Primary funding sources for the medical unit are third party payers captured under "Other" funds: Medicare, Medicaid, and private insurance. Since the vocational unit primarily serves VR clients, it is largely funded with federal dollars known as 110 funds.5

5 Section 110 of the federal Rehabilitation Act of 1973 authorized grants to states to fund vocational rehabilitation programs for individuals with disabilities.

Roosevelt Warm Springs Institute for Rehabilitation

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Exhibit 7 Institute Revenue and Expenditures Fiscal Years 2010-2013

Revenue

2010

2011

2012 2013 Projected

Vocational
Medical Other2 Total Revenue

State Federal1
Other Total Vocational
State Other Total Medical
Total Other

1,744,879 12,525,122
134,799

1,987,072 22,575,520
213,647

1,129,940 15,059,741
429,395

14,404,800 24,776,239 16,619,075

3,674,316 6,989,289 1,082,896
11,746,501

4,092,526 17,660,531 21,753,057

3,443,208 15,691,030 19,134,238

4,303,200 18,162,139 22,465,339

6,955,168 13,439,068 20,394,236

191,655

155,007

-

$ 36,349,512 $ 44,065,484 $ 39,084,415 $

62,517 32,203,254

Expenditures

Institute Costs Personal Services Purchased Services Supplies Capital Buildings3 Utilities Repairs and Maintenance Equipment Dues Subscriptions Rent Lease Telecommunications Computer Charges Travel Administrative Allocation Adjustment Other
Total Institute Costs

21,598,800 4,277,092 2,343,616 1,317,595 976,781 796,487 590,835 417,593 298,101 238,259 222,610 19,680 34,209
$33,131,658

22,853,077 3,595,537 2,585,221 8,288,700 1,084,586 1,656,479 222,822 41,797 388,363 245,128 186,691 22,918 65,555
$41,236,874

22,780,362 4,063,876 2,548,180 1,248,874 899,521 561,517 1,774,109 68,472 408,283 300,064 221,563 23,875 (64,595) 49,268
$34,883,369

21,823,001 4,805,446 2,014,196 821,634 658,711 174,251 15,000 285,953 74,289 195,000 20,000 -
$30,887,481

Costs Outside of Institute4 GDOL Indirect Cost Allocation Other GDOL/DHS Expenses

3,064,988 540,712

3,180,075 475,936

3,373,464 516,366

900,000 1,278,601

Total Expenditures

$ 36,737,358 $ 44,892,884 $38,773,199 $ 33,066,082

Revenues Over (Under) Expenditures5 $ (387,846) $ (827,400) $ 311,216 $

(862,828)

1The vocational unit received federal funding of $956,664 in fiscal year 2010 and $8,073,005 in fiscal year 2011 towards the

construction of a new dorm. Bonds provided matching state funds, which are not included in the Exhibit.

2Other includes revenue earned in miscellaneous areas, such as the golf course, conference center, and staff housing. 3Fiscal year 2011 includes new dormitory building expenditures.

4A GDOL indirect cost allocation, as well as other miscellaneous costs, were incurred on behalf of the Institute but billed to

other programs (e.g., Administration, IT, etc.).

5Any Institute expenses incurred in other programs that were not covered by Institute revenue were paid for with available

funds in those other programs.

Source: GDOL records; Institute records

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Development Fund
The Roosevelt Warm Springs Development Fund (the Fund) was formed in 1986 as a non-profit fundraising organization for the Institute. It is governed by a 10-member board6 and is legally separate from the Institute. It finances projects such as building construction, cottage restoration projects, and facility improvements. In fiscal year 2011, the Fund collected $881,148 in revenue and expended $391,902 on Institute programs and its own operations.
Other States Nationally, the Institute is one of eight state-operated comprehensive rehabilitation centers (CRCs). The seven other states that operate CRCs are Arkansas, Kentucky, Maryland, Michigan, Pennsylvania, Tennessee, and Virginia. West Virginia previously operated a CRC, but it was closed in 2007 due to a funding shortfall.
A CRC provides training, counseling, and medical support to individuals with disabilities in a residential setting. Besides vocational training, all eight CRCs provide some level of instruction in independent living and academics. Beyond these basic characteristics, centers vary in number of individuals served, services offered, eligibility, and program performance measurement. Appendix B summarizes characteristics of state-managed CRCs.
The Roosevelt Warm Springs Institute for Rehabilitation is currently the only CRC to offer inpatient medical services and one of two that offer outpatient medical services to the general public. Kentucky's CRC also offers outpatient services to the general public, but typically over 90% of patients are students or VR clients. While most other states limit medical services to students and/or VR clients, Georgia's medical unit primarily serves the general population and provides limited services to vocational students. Students may receive such services as physical and occupational therapy or nutrition counseling through the medical unit.

6 The Institute's Executive Director is a nonvoting member of the Fund's Board of Trustees.

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Findings and Recommendations

Medical Rehabilitation Unit

The practice of using state appropriations to subsidize the Institute's Medical Rehabilitation Unit is questionable and has impacted the state's ability to maximize federal vocational rehabilitation funds.
The medical unit's revenue generally does not cover the cost of the medical services it provides. As a result, the Institute allocates the majority of its state appropriation to cover the shortfall for its medical operations, effectively subsidizing medical care for the general public with state funds. The medical unit receives payment for patient services from a variety of sources including Medicare, Medicaid, commercial medical insurance, and private pay; however, as shown in Exhibit 8, the medical unit would have incurred a loss of approximately $1.5 million and $755,000 without state appropriations in fiscal years 2011 and 2012, respectively. In its amended fiscal year 2013 budget, an additional $5 million in state funds was appropriated to cover expected revenue shortages in the medical unit.
It is important to note that if the Institute redirected the state funds it uses to support the medical unit for vocational purposes, the state would be eligible for additional federal funding. For example, $3.4 of the Institute's $5.4 million state appropriation was used to help cover the medical unit's losses in fiscal year 2011. If these funds were instead used for vocational costs, the state would have been eligible for an additional $12.9 million in matching federal funds to be used toward vocational rehabilitation services.

Exhibit 8 Medical Unit Expenses Exceed Earned Revenue Fiscal Years 2010-2013

Revenue State Funds Other Funds Total Medical Unit Revenue

FY10

%

FY11

%

FY12

% FY13 projected %

$4,092,526 $17,660,531 $21,753,057

18.8% 81.2%

$3,443,208 $15,691,030 $19,134,238

18.0% 82.0%

$4,303,200 $18,162,139 $22,465,339

19.2% 80.8%

$6,955,168 $13,439,068 $20,394,236

34.1% 65.9%

Expenditures Total Expenditures1

$21,943,989

$17,162,579

$18,916,925

$20,869,388

Revenue Over (Under)

Expenses without State

($4,283,458)

($1,471,549)

($754,786)

($7,430,320)

Funds

1Projected expenditures for fiscal year 2013 do not include any of the Institute's administration and support costs that will be allocated to the

medical unit.

Source: GDOL records; Institute records

These figures reflect financial data received from Georgia Department of Labor (GDOL) and the Institute. Medical unit costs are significantly different when comparing fiscal year 2010 to 2011. According to GDOL, these differences are due to a new administrative cost allocation methodology implemented in fiscal year 2011, which resulted in more of the Institute's administrative costs being allocated to the vocational unit and fewer allocated to the medical unit. However, we were unable to obtain the formula used prior to fiscal year 2011 to determine the extent to which the change affected the Institute's finances. In addition, the financial figures included in Exhibits 8-11 do not include any GDOL indirect costs that were allocated to the Institute. Each year, GDOL allocated approximately $3 million to the Institute for indirect services it provided, but these indirect costs were not divided among the vocational and medical units.

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13

In addition to the medical unit's operating losses, its inpatient facilities require renovations. As noted in more detail on page 25, the inpatient building is approximately 80 years old and has not been renovated since the 1980s. The total cost to repair and renovate this building is estimated at approximately $2.3 million.
A key factor in the medical unit's operating deficit is low utilization rates. The unit serves individuals who could receive similar medical services from other medical providers. As discussed throughout the remainder of the finding, geographic location of the Institute and competition from other medical providers contribute to the medical unit's low utilization rates. It should be noted that we did not assess the unit's business operations which could impact the medical unit's operating income. These business operations include medical billing rates, collections of patient receivables, and non-acceptance of certain payor types. Nationally, the Institute is one of eight state-operated comprehensive rehabilitation centers (CRCs) but is currently the only CRC to offer inpatient medical services and one of two that offer outpatient medical services to the general public.
As discussed below and on the following pages, the three medical operations (Inpatient Rehabilitation Facility, Long Term Acute Care Hospital, and Outpatient Services) that comprise the medical unit contribute to the overall financial losses. Each operation generally does not earn sufficient revenues to cover its expenditures.
Inpatient Rehabilitation Facility (IRF)
In fiscal year 2010 and 2011, the IRF had an operating loss of approximately $2.3 and $1.1 million, respectively. To offset the operating loss, the Institute allocated approximately $2.5 and $2.1 million of its state appropriation to the IRF. During our review, we determined operating losses are related to underutilization of the IRF. For example, between fiscal years 2009 and 2011, the occupancy rate averaged 37% and admissions decreased 4%. While the hospital is licensed for 52 beds, the average daily census was typically 17-20 patients during this period. To have been selfsufficient in fiscal years 2010 and 2011, the IRF would have needed to increase the number of patient bed days by approximately 27% and 18%.7 Exhibit 9 shows a variety of financial and utilization statistics that highlight some of the issues related to IRF operations.
Two key factors impacting utilization of the IRF are location and competition. Appendix C shows the IRF primarily serves patients in its immediate area. In fiscal year 2011, 66% of patients admitted to the IRF came from Meriwether County (where the Institute is located) and eight neighboring counties. The Institute is in a rural part of the state that is not highly populated compared to more urban areas where the majority of other IRFs in the state are located.
Furthermore, the IRF serves individuals who could receive similar medical services from other medical providers. As shown in Appendix C, there are currently 33 other IRFs in the state, many of which are located in major cities. Two of these IRFs are located within 55 miles of the Institute. Additionally, the Georgia Department of Community Health (DCH) projected that by the year 2017 there will be a surplus of IRF beds in the Institute's region and statewide.

7 These percentages are estimates based on total program expenditures each year plus additional personnel costs necessary to serve additional patients.

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14

Exhibit 9 Inpatient Rehabilitation Facility Financial and Utilization Statistics Fiscal Years 2009-2011

Expenses Exceed Earned Revenue

Fiscal Years 2010 and 2011

FY10

%

FY11

Revenue

State Funds

$2,468,904 19% $2,051,292

Other Funds

$10,855,761 81% $9,987,517

Total Revenue

$13,324,665 100% $12,038,809

%
17% 83% 100%

Expenditures Total Expenditures $13,156,375
Revenue Over (Under) Expenses without State Funds ($2,300,614)

$11,123,244 ($1,135,727)

Decrease in IRF Utilization1 Fiscal Years 2009-2011

Activity

FY09 FY10 FY11 % Change

Admissions

469 469 449

-4%

Patients Served 474 470 445

-6%

Occupancy Rate 38% 39% 34%

1Patients admitted and discharged on the same day have been excluded. Also note that some patients have multiple admissions in a given year.

Average Daily Census Well Below Capacity Fiscal Years 2009-2011

60

50

Number of Beds

40

30

20

20

20

17

10

0 FY09

FY10

FY11

Licensed Beds (52 beds)

Average Daily Census

Source: Institute and GDOL records

Increase in Bed Days Needed to Break Even Fiscal Years 2010 and 2011

10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

9,336 7,355
Increase 27% FY10
Actual Bed Days

7,496 6,374
Increase 18% FY11
Bed Days Needed

1Bed Days Needed determined by dividing total expenses by the average revenue earned per actual bed day.

Long Term Acute Care Hospital (LTACH)
In fiscal year 2011, LTACH revenues exceeded expenditures by approximately $740,0008; however, the LTACH had an operating loss of approximately $700,000 in fiscal year 2010. The Institute allocated approximately $1.4 and $1.2 million of its state appropriation to the LTACH in fiscal years 2010 and 2011, respectively. Similar to the IRF, we determined operating losses are related to underutilization of the LTACH. For example, between fiscal years 2009 and 2011, the occupancy rate averaged 38% and admissions decreased 6%. While the hospital is licensed for 32 beds, the average daily census was typically 11-13 patients during this period. Exhibit 10 shows a variety of financial and utilization statistics that highlight some of the issues related to LTACH operations.

8 LTACH expenditures were 41% lower in fiscal year 2011 compared to fiscal year 2010. As noted on page 12, GDOL stated this decrease was due to a change in the way administrative costs were allocated in fiscal year 2011.

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15

Two key factors impacting utilization of the LTACH are location and competition. Appendix C shows the LTACH primarily serves patients in its immediate area. In fiscal year 2011, 74% of patients admitted to the LTACH came from Meriwether County and eight neighboring counties. The Institute is in a rural part of the state that is not highly populated compared to more urban areas where the majority of other LTACHs in the state are located.

Furthermore, the LTACH serves individuals who could receive similar services from other medical providers. Appendix C shows there are currently 14 other LTACHs in the state, many of which are located in major cities. Two of these LTACHs are located within 55 miles of the Institute. Additionally, DCH projected that by the year 2017 there will be a surplus of LTACH beds in the Institute's region.

Exhibit 10 Long Term Acute Care Hospital Financial and Utilization Statistics Fiscal Years 2009-2011

LTACH Revenue and Expenditures

Fiscal Years 2010 and 2011

FY10

%

FY11

Revenue

State Funds

$1,427,165 19% $1,209,161

Other Funds

$5,981,399 81% $4,659,098

Total Revenue

$7,408,564 100% $5,868,259

%
21% 79% 100%

Expenditures Total Expenditures

$6,682,644

$3,916,975

Decrease in LTACH Utilization

Fiscal Years 2009-2011

Activity

FY09 FY10 FY11 % Change

Admissions

160 174 150

-6%

Patients Served 171 175 152

-11%

Occupancy Rate 42% 39% 35%

Revenue Over (Under) Expenses without State Funds

($701,245)

$742,123

Average Daily Census Well Below Capacity Fiscal Years 2009-2011

Number of Beds

35

30

25

20

15

13

10

5

0 FY09
Licensed Beds (32 beds)

12 11

FY10

FY11

Average Daily Census

Source: Institute and GDOL records

Bed Days Needed to Break Even Fiscal Years 2010 and 2011
6,000

5,000 4,000 3,000

5,455 4,526

4,058 3,871

2,000

1,000

Increase 21%

Decrease 5%

0 FY10
Actual Bed Days

FY11 Bed Days Needed

1B ed Days Needed determined by dividing to tal expenses by the average revenue earned per actual bed day.

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Outpatient Services
In fiscal years 2010 and 2011, the outpatient program had operating losses of approximately $1.3 and $1.1 million, respectively. To offset the losses, the Institute allocated nearly $200,000 of its fiscal years 2010 and 2011 state appropriation to support outpatient operations. We determined the operating losses were related to low utilization. For example, between fiscal years 2009 and 2011, the total number of visits decreased 19%, from 8,043 to 6,523 visits. To have been self-sufficient in fiscal years 2010 and 2011, the outpatient program would have needed more than double the number of patient visits. Exhibit 11 shows a variety of financial and utilization statistics that highlight some of the issues related to the Institute's outpatient operations.

Two key factors impacting utilization of the Institute's outpatient services are location and competition. The majority of patients at each clinic come from the immediate area. The outpatient clinics also face competition from other providers, especially in LaGrange and Newnan. For instance, the Newnan clinic stopped providing outpatient therapy services during fiscal year 2010 due to competition from other providers.

Exhibit 11 Outpatient Financial and Utilization Statistics Fiscal Years 2009-2011

Expenses Exceed Earned Revenue

Fiscal Years 2010 and 2011

FY10

%

FY11

%

Revenue

State Funds

$196,457 19.3% $182,755 14.9%

Other Funds

$823,371 80.7% $1,044,415 85.1%

Total Revenue

$1,019,828

$1,227,170

Expenditures Total Expenditures $2,104,970

$2,122,360

Significant Decrease in Outpatient Visits

Fiscal Years 2009-2011

Activity1

FY09 FY10 FY11 % Change2

Visits

8,043 6,874 6,523

-18.9%

Patients Served 1,897 1,755 1,903

0.3%

1T hese figures include outpatient physician visits to other medical facilities but do not include Rehabilitation T echnology services.

2T he Newnan clinic stopped providing therapy services during fiscal year 2010 due to competition from other providers in the area.

Revenue Over (Under) Expenses ($1,281,599) without State Funds

($1,077,945)

Average Number of Services Provided per Day Fiscal Years 2009-2011

Increase in Visits Needed to Break Even1 Fiscal Years 2010 and 2011
25,000

30

25

25

26

25

20

20,000 15,000

22,457

15,375

15 13
10 10
5

14 8

14 9

0 FY09

FY10

FY11

Warm Springs LaGrange Newnan
1A service is any o utpatient pro cedure (e.g., therapeutic exercise). A patient may receive multiple services during a single visit.

Source: Institute and GDOL records

10,000

5,000 0

8,784
156% Increase
FY10

7,566
11030%3% IInnccreraesaese
FY11

Actual Visits

Visits Needed

1T his analysis includes outpatient physician visits to other medical facilities as well as Rehabilitation T echnology services. 2Visits needed determined by dividing total expenses by the average revenue earned per visit.

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RECOMMENDATION
The General Assembly and GVRA should review the long-term viability of the Institute's medical unit. If the medical unit remains open, the General Assembly should determine the extent to which it will continue to subsidize the operation. An evaluation is needed to determine whether any proposed options to improve the medical unit's financial circumstances would generate the revenue necessary to meet the desired level of profitability on a long-term basis.
GVRA Response: GVRA, the Governor's Office, and the General Assembly have initiated a review and action plan to address the long term viability of the medical unit. Effective July 1, 2013, the Institute will enter into an interagency agreement with Georgia Regents University to manage the medical hospitals to enhance the delivery of care. This agreement will allow an increased financial investment in vocational services which will increase federal match funds. Additionally, operations of all three outpatient medical clinics as well as Durable Medical Equipment were discontinued on April 30, 2013.

Vocational Rehabilitation Unit

The Institute does not track the outcomes of its vocational students to determine how well it is meeting program objectives of preparing students for employment and independent living.

Output Measures Indicate the amount of services provided
Outcome Measures Assess how well a service's objectives are accomplished

The Institute measures its vocational program effectiveness using the program completion rate. While the completion rate measures one aspect of performance, it does not measure the extent to which its primary objective of employment is being accomplished. In addition, the Institute has no outcome measures related to evaluating students' increased capacity to live independently, a secondary objective of the vocational program. As a result, the Institute cannot demonstrate the effectiveness of its residential vocational program.
Our review found that other states' comprehensive rehabilitation centers (e.g., Virginia, Michigan, and Kentucky) track and report their students' employment outcomes. Administrators from these states indicated their primary sources for employment information are their states' VR databases, but follow-up phone calls to graduates also provide supplementary information. In addition, Virginia utilizes unemployment data from the Virginia Employment Commission.
Employment Rates
Employment is the vocational program's primary goal, but the Institute has not measured the extent to which its students obtain employment after discharge from the program. To evaluate employment outcomes, we matched records for 583 students discharged in fiscal years 2009 through 2011 to two databases: wages reported by employers to the Department of Labor's Unemployment division and VR's Georgia Rehabilitation Online Works (GROW) case management database.9

9 The Georgia Department of Labor does not require some employment information to be reported (e.g., work for a nonprofit with less than four employees), so GROW was used to supplement the Unemployment data.

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It is important to note these employment rates measure whether the student was employed at any point during the time period specified, regardless of employment length.
As shown in Exhibit 12, we found that, of the 392 students who graduated as Work Ready, 44% worked at some point in the first year after discharge and 45% worked at some point in the second year.10 Average wages earned by Work Ready students rose from $5,117 in the first year to $7,861 in the second year.

Exhibit 12 44% of Work Ready Students Were Employed in the First Year Students Discharged in Fiscal Years 2009-2011

Disposition

1st Year After Discharge

Number Average

of

Length of Employment Average

Students Stay (Days)

Rate2

Wages Earned3

2nd Year After Discharge1

Employment Rate2

Average Wages Earned3

Work Ready

392

273

Other Dispositions 4

191

129

44% $ 29% $

5,117 3,763

45% $ 34% $

7,861 5,662

Total

583

226

39% $ 4,789

41% $

7,281

1Second year employment w as analyzed for 394 students discharged in fiscal years 2009-2010. Assumptions regarding

continued employment w ere made w hen incorporating GROW data for 17 (4%) cases successfully closed during the first

year after discharge.

2Percent of all students w ho w ere employed at some point during the year, regardless of employment length.

3Average annual w ages earned for students w ho w ere employed at some point during the year. Seven students obtained unpaid w ork and are counted as employed w ith w ages of $0. 4Excludes students discharged as School Ready. Sufficient information w as not available to evaluate the rate at w hich School Ready students w ent on to attend post-secondary school after discharge from the vocational program.

Source: GDOL Unemployment w age database and VR GROW database

Another measurement of employment outcomes is the wage earned by a student after discharge from the Institute. Wages for employed students were generally lower than substantial gainful activity (SGA) levels.11 SGA for calendar years 2010 and 2011 was $1,000/month for non-blind and $1,640/month for blind individuals.12 We found that 7% of all employed students earned more than annualized SGA in the first year after discharge, and 18% percent earned more than SGA in the second year.
According to staff, follow-up phone calls were previously conducted six months after a student's discharge to ask about employment and wages, but these have been discontinued. We observed no documentation of follow-up during our review of a sample of 68 student files. However, management has stated that the Institute will place a greater emphasis on employment outcomes in the future and student surveys after discharge will be reintroduced.

10 Since the Institute has not established any benchmarks against which vocational program outcomes can be compared, we are unable to determine whether the employment outcomes we identified are acceptable. 11 The Social Security Administration considers a person with a disability earning more than a certain monthly amount to be engaging in SGA and not eligible for Social Security disability benefits. 12 To simplify calculations, we used 2010-2011 SGA amounts for all students. Approximately 2% of students evaluated had a visual impairment and were compared against the $1,640/month level.

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Also, prior to the summer of 2012, Institute employees did not have access to VR's GROW database, which provides case information, including employment outcomes, for VR clients. In the future, Institute staff will be able to utilize GROW to identify students whose VR cases were closed successfully, indicating 90 days of employment. GROW also records the student's weekly wage and hours at case closure.
Independent Living
Institute management indicated that independent living is an objective of the vocational program. Students typically undergo a month of independent living training at the beginning of their stays, which includes classes such as money management, communication, and grooming and hygiene; and students continue to practice these skills through the remainder of their stay at the Institute. However, the Institute has no performance measures related to independent living. Additionally, it does not assess the training provided by measuring student gains in independent living skills. To evaluate outcomes for this training, the vocational program could measure the extent to which its graduates can perform trainingrelated activities of daily living after returning to the community and compare this to students' pre-training scores.
RECOMMENDATION
To monitor program effectiveness, the Institute should implement a process to analyze the employment and independent living outcomes of its vocational student population after discharge. It should also develop criteria appropriate for its student population to compare these outcomes against. Management should utilize this information to help identify strategies to improve program effectiveness.
GVRA Response: Over the past year, the Institute has initiated a transformation of its vocational services to specifically focus on measurable employment and independent living outcomes.

The Institute should develop consistent, measureable assessment criteria to determine when students have successfully completed the vocational program and a performance goal for a reasonable level of vocational services after discharge.
While the Institute tracks vocational program completion rates as a primary performance measure, the decisions to "graduate" students from the program are not based on a standardized determination process. In addition, we found a significant number of students received additional vocational services after discharge. Those students who completed the program as Work Ready required services at similar rates to students with other discharge dispositions. Also, the Institute has not developed a performance goal regarding a reasonable level of post-graduate services.
Work Ready Assessment
During our review, we found no evidence that a Work Ready disposition is determined using consistent criteria prior to discharge. Although the Institute's performance measures indicate work readiness is based on 16 standard work readiness behaviors, Institute staff could not provide a list of these behaviors.

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Additionally, Institute policies do not indicate a method for how work readiness will be determined or include a standard form to document the determination. Instead, work readiness appears to be based on staff's general observations of a student's work habits.

We reviewed a sample of 68 student files and found that none of the files of the 45 students classified as Work Ready documented how the staff determined the student to be Work Ready. Files included assessments for certain program areas and notes of individual achievements such as performance at a certain worksite, but no overall assessments of work readiness were found.

While the vocational program lacks a formal work readiness determination process, it does track the number of students completing the program. As shown in Exhibit 13, 67.5% of discharges in fiscal year 2011 had Work Ready or School Ready discharge dispositions, which is below the Institute's performance goal of 70%. Completion rates over the previous two years were also below the program's goal, with 65.4% in 2009 and 66.5% in 2010.

Exhibit 13 Completion Rate Is Below the 70% Goal Fiscal Year 2011 Discharges

Discharge Status

Number Percentage

Completed Program

135

67.5%

Did Not Complete Program

65

32.5%

Total Students

200

100.0%

Source: Institute records

VR Services after Discharge
We found that 70 of 378 (18.5%) Work Ready students discharged in fiscal years 2009-2011 received one or more vocational services provided at the Institute after they returned home. These services included work adjustment, independent living, and employment readiness training. Furthermore, files for 15 of the 45 (33%) Work Ready students included discharge recommendations for additional training to help prepare the student for employment, indicating the Institute counselor may not have considered the student fully ready to enter the workforce. Although some services may be necessary or expected after program completion, evaluation of the services needed and which students require them could lead to improvements in the Institute's vocational program or be considered in developing completion criteria. To assess the Institute's services and determine a reasonable level of VR services after discharge, we surveyed VR field counselors. However, only 42 of the 238 (17.6%) field counselors responded to the survey, so the results were not usable.
Students completing the program as Work Ready received similar levels of work adjustment training and on-the-job services after discharge as students with other dispositions.
As shown in Exhibit 14, 15.6% of students discharged as Work Ready received work adjustment training after returning to the community. Work

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adjustment training is typically provided to students while at the Institute. It involves placing the student at a work site to develop acceptable work habits and behaviors. The percentage of students undergoing work adjustment training after leaving the Institute and the amount of that training did not vary significantly between Work Ready students and other discharge dispositions. We used the cost of the training as a measure of the amount of services received since actual number of service hours the student received was not available.

Of the 153 Work Ready students whose VR cases were successfully closed (indicating employment for at least 90 days), 40 (26.1%) required VR services on the job prior to case closure. These services included job coaching, job retention, supported employment, and on-the-job training. Our sample file review found that Institute counselors may recommend some on-the-job services for Work Ready students. Staff indicated these services may be required due to the severity of the student's disability. However, as shown in Exhibit 14, a student's completion of the program as Work Ready did not significantly decrease the likelihood that such services would be needed or reduce the cost of the services.

Exhibit 14 Similar Need for VR Services After Discharge Fiscal Year 2009-2011 Discharges

Total

Average

Disposition Group Students Rate

Cost

Work Adjustment Training

Work Ready

378 15.6% $2,581

Other Dispositions

202 15.8%

On-the-Job Services

Before Successful Case Closure

Work Ready

153 26.1%

$2,561 $2,598

Other Dispositions

41 26.8% $2,207

Source: VR GROW database

RECOMMENDATION
To ensure students' preparation for employment is properly assessed prior to discharge, the Institute should clearly define completion criteria and standardize the method used to determine and document students' readiness to enter the workforce. Additionally, the Institute should track what VR services are required after discharge and develop a performance goal regarding a reasonable level of services for the student population. Consistent, documented evaluations of work readiness prior to discharge and of needed services after discharge could also identify opportunities for program improvement.
GVRA Response: Internal Institute training and supervision of vocational rehabilitation counselors has been implemented to more closely monitor program planning for effective discharge dispositions. A quantified core curriculum and program of study requirements will ensure reduced redundancy of services post-discharge. Institute job placement services will also reduce the need for additional services post-discharge.

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The Institute should evaluate the effectiveness of individual vocational services and admission criteria.

The Institute's vocational program provides a variety of vocational rehabilitation services, but it has not assessed the effectiveness of individual services, which training programs to offer, or which students are best suited for the program. As discussed on page 17, the Institute does not measure student outcomes after discharge. As a result, it cannot determine the impact of individual services on the program objectives of employment and independent living.

Additional analysis in the following areas would provide management with information to increase the effectiveness of the program:

Assess training and services (including Independent Living, Behavioral Management, Production Support Workshop, Work Adjustment, Academic Education) The Institute does not measure student improvement in each area, nor does it evaluate each program component's impact on student outcomes after discharge. We found student information is not aggregated or maintained in databases to facilitate evaluation. Individual student files generally include documentation of competency gains for individual training areas and worksite experiences. However, the information system and management reports do not track which services students receive or document improvement in these areas. For instance, student files show grade level increases in reading and math, but the Institute does not measure overall academic improvements for the student population.

Institute Occupational Skills Training Programs:
Business and Information Technology
Healthcare
Information Technology Enterprises
Materials Handling

Track occupational skills training The Institute does not systematically track which students participate in and/or complete its occupational skills training programs. As a result, the Institute cannot evaluate the effectiveness of these programs by evaluating overall employment or employment in the field of study. Additionally, the Institute could not reliably determine the total number of students in the training programs, preventing management from analyzing program efficiency measures, such as student-to-instructor ratios. Note that students may choose one of four occupational skills training programs offered at the Institute, but not all students participate in occupational skills training.
We found that comprehensive rehabilitation centers in other states track the effectiveness of training services provided. For example, Michigan and Virginia track and report both activity data and employment outcomes (including the percent employed in the field of study) by occupational skills program.

Research labor market The Institute should consider improving the process it uses to assess its skills training programs. While Institute management indicated that skills training program offerings are based on staff knowledge of the job market, conversations with VR field counselors, programs offered by other state comprehensive centers, and conversations with students about areas of interest, additional steps could be taken. For example, we evaluated Georgia Department of Labor employment projections for areas of study offered by most other states but not by the

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Institute and noted training areas, such as food service, with strong employment prospects in the state. (See Appendix D for a list of skills training programs at each state's center.) The Institute should evaluate potential skills training areas and determine which, if any, should be added or removed.
We found that other states' comprehensive rehabilitation centers conduct formal labor market research to help determine which skills training programs to offer. For example, Michigan conducts formal reviews of its training programs each year and Maryland conducts a review every three years. Additionally, standing business advisory committees help direct program curriculum in Maryland, Michigan, and Virginia.
Evaluate admission criteria The Institute has not formally evaluated student outcomes to determine if admission criteria identify those with the greatest ability to benefit from its vocational services. Staff indicated the criteria were developed over time with input from vocational program psychiatrists and medical staff, but no formal evaluation has been conducted that considers program outcomes.
Utilizing students' completion and outcome data, the Institute should identify characteristics of individuals most likely to respond to the services and environment on campus. Such characteristics might include age and type of disability. Defining these characteristics does not imply excluding students with more severe disabilities, but rather identifying those best served by the program. The vocational program could make more effective use of its resources by ensuring its admissions criteria and services are aligned.
While services received and student achievements may be noted in hard copy files, the information is not aggregated or summarized for analysis. The information system used to track program activity is primarily a healthcare information system used by the medical unit and is not structured to capture the specific components needed to assess the vocational program's effectiveness. Although the Institute has the ability to manually compile reports to track and measure useful program information, it has not done so consistently.
RECOMMENDATION
The Institute should expand its analysis of the vocational program and implement a more comprehensive tracking and reporting system to improve program performance. We recommend the Institute track which services students utilize, monitor student improvement and outcomes in each program area, research the labor market to identify occupations with the strongest employment potential, and evaluate admission criteria based on actual student outcomes.
GVRA Response: Outcomes measures have been identified for every program area and position to track and trend performance and student outcomes. Management has adopted accountability at all levels of the vocational unit. A Student Information System is currently being purchased to track student information from recruitment through job placement beginning in FY2014 and will provide a basis of outcome data collection. Designated Institute staff will be working closely with the vocational unit to track and trend information on an on-going basis, as well as at designated

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junctures each year. Key management level positions have been identified to provide additional leadership in career and technical education, as well as employment planning and placement. Special programs are also in the process of development to provide training and development for special populations to expedite program completion and access to unique services to support employment success. Admissions criteria will be re-defined in FY2014 for direct access to career and technical education, as well as other programs supportive of preparing students to enter occupations with strong employment potential.

Facilities

Several buildings on the Institute's campus have deteriorated to the point of requiring extensive renovation, repair, or demolition.

Renovation Construction project involving the installation or replacement of major building components
Repair Work to restore damaged or wornout property to a normal operating
condition

The Institute's Warm Springs campus consists of 72 buildings, the majority of which are older, historic structures. Of the 72 buildings, 17 are unusable due to their deteriorated condition. These unusable buildings total 19% of the Institute's total square footage. In addition to the unusable buildings, several inhabitable buildings still require renovations and repairs, some of which are extensive. Known renovation and repair costs total an estimated $10.1 million13; however, cost estimates to renovate, repair, or demolish some buildings have not been determined by the Institute, which would further increase this estimate.
Discussed below are specific buildings or groups of buildings that require renovation or repair. When available, the estimated costs are also included. It should be noted that while we are highlighting several buildings in poor condition, the campus includes some newer buildings in good condition including the new dormitory, recreation center, and outpatient building.

"There are no cottages that do not need some level of renovation or repair regardless of whether they are currently in use or
not."

Historical Cottages The Institute's campus includes 31 cottages, most of which were built for or came into ownership of patients or staff of the hospital during the 1920s and 1930s. Fifteen of the cottages are unusable due to needed repairs such as new roofing and electrical systems. Many of the remaining cottages that are inhabitable also need repair. In 2011, an architectural firm hired to assess the Institute's cottages estimated that renovations to 27 of the cottages would cost approximately $6.9 million (average of $254,630 per cottage).14 The assessment concluded that funding has been adequate to maintain the cottages for habitation but inadequate to effect major repairs as they become necessary. During our visits to the campus, we observed holes in cottage walls, hanging gutters, hanging light fixtures, overgrown grass, dented doors, broken fences, broken windows, peeling paint, damaged porches, and rusted walls. The pictures in Exhibit 15 on page 26 illustrate the condition of many of the cottages.

13 Estimate includes renovation and repair costs for 27 historical cottages, the inpatient building, an administrative building (Founders Hall), and various facility projects.
14 The Roosevelt Warm Springs Development Fund is working in conjunction with organizations such as Rotary International to raise funds to restore the historic cottages.

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Old Dormitory The old dormitory is over 85,000 square feet and has been vacant since a new dormitory opened in late 2011. It needs a new roof, new mechanical and electrical systems, and asbestos remediation. Staff have discussed various options regarding the future plans for the building including demolition, letting it sit empty, or repurposing with renovations. However, no decisions have been made regarding the building's future use, and the Institute has not determined cost estimates for the various options available. Pictures of the old dormitory can be found in Exhibit 16 on page 27.
Inpatient Building The inpatient building, which houses the Inpatient Rehabilitation Facility and Long Term Acute Care Hospital, is approximately 80 years old and has not been renovated since the 1980s. A formal assessment of the inpatient facility was not conducted until October 2012 when Georgia Regents University requested an assessment be conducted before exploring possible partnership options with the Institute. The assessment, conducted by the Georgia State Financing and Investment Commission, found the building is in overall good condition but many interior and exterior renovations are needed. Immediate needs include minor roof repairs, window replacements, and new carpet. Repairs needed in the next three to five years include chiller replacements, new wallpaper, and painting of interior walls and ceilings. The total cost to repair and renovate the inpatient building was estimated at $2.3 million. It should be noted that this amount does not include the costs to repair or upgrade any hospital equipment that may be needed to improve medical operations.
Founders Hall This building, which houses administrative staff, needs a complete renovation and asbestos remediation. The Institute's fiscal year 2014 capital outlay plan included new electrical and fire alarm systems as well as survey and space planning design for Founders Hall. The cost was estimated at $516,000.
The renovation and repair needs mentioned above are not an exhaustive list. Institute staff provided a list of facility projects for other buildings such as the camp, conference center, and recreation center. These facility projects are estimated to cost approximately $400,000. Cost estimates for other buildings and spaces needing renovations and repair have not been determined and are not included in these estimates. In addition to these costs, the Institute has on-going repair and maintenance costs. In fiscal year 2012, building and grounds maintenance costs totaled approximately $1.3 million.

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Exhibit 15 Several Cottages in Poor Condition

Keith Morgan Cottage

Keith Morgan Cottage

Huntington Cottage

Carpenter Cottage

Pierson Cottage
Source: Photographs taken by audit team

Pattison Cottage

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Exhibit 16 Condition of Other Buildings on Institute Campus

Wilson Pool

Children's Solarium

Wilson Office Building

Inpatient Building Window

Old Vocational Dorm

Old Vocational Dorm Room

Source: Photographs taken by audit team and Georgia State Financing and Investment Commission

Roosevelt Warm Springs Institute for Rehabilitation

28

According to the Institute, the condition of many of its buildings results from a pattern of deferred maintenance. Due to limited funding, Institute maintenance staff were asked to only perform the minimum repair necessities on the cottages, especially on those that are vacant (e.g., checking roofs, making sure windows and doors are secure).
There are also restrictions on building demolition. Since the Institute's campus has been designated as a National Historic Landmark, it must consult with the Historic Preservation Division (Georgia Department of Natural Resources) before significantly altering the characteristics of the property. Also, if federal funds are used for the project or the agency is seeking federal licensing or permits, the U.S. National Park System Advisory Board must be provided an opportunity to comment on changes to historic properties. However, in both cases, agencies are not obligated to adhere to the comments or recommendations made by the reviewers.
RECOMMENDATION
The Institute should create a complete master facility plan that includes future plans and costs for its uninhabitable and deteriorating buildings. Staff should identify potential uses for its buildings to justify the investment needed to renovate, repair, or maintain the buildings. Repair and maintenance funding should be prioritized based on usage of buildings and historical significance. Specifically, GVRA and the Institute should determine whether it would be more beneficial to demolish some of the 31 historical cottages rather than continue to maintain them all. Last, the Institute should consider "moth-balling" buildings not chosen for renovation or repair in the near future to prevent further deterioration. This would involve securing the building and its components and providing adequate ventilation.

Auxiliary Programs
The Institute should monitor the profitability of each of its revenue-generating activities on an on-going basis.
The Institute operates several revenue-generating activities, including a camp, conference center, and recreation center. The Institute also has a golf course that is currently closed. Because the Institute does not maintain complete profit and loss (P&L) statements for each of these activities, it cannot determine the profitability of the activities. While the revenue-generating activities may have purposes other than generating a profit, P&L statements would allow the Institute to better monitor the activities and evaluate steps that should be taken to maximize revenue generation when necessary.
Using information obtained from the Institute, we attempted to determine the profitability of each activity. As shown in Exhibit 17, we found that some programs do not generate sufficient revenue to support operations and require state and federal funding assistance. For example, the camp generated approximately $90,000 in fiscal year 2012 while expenditures totaled $96,000. It should be noted that since the Institute does not separately track expenditures related to conference center rentals, management cannot determine the profitability of its external conference center activity.

Roosevelt Warm Springs Institute for Rehabilitation

29

Exhibit 17

Institute Revenue-Generating Activities

Fiscal Year 2012

Conference Recreation Golf

Camp

Center1

Center Course2

Generated Income

$90,265

$70,195

$30,689

$0

Expenditures

96,454

n/a

461,616 30,082

Profit/Loss from Operations

-$6,189

n/a

-$430,927 -$30,082

State Revenue

$1,318

n/a

$91,787 $30,082

Federal Revenue

4,871

n/a

339,140

0

Total Other Revenue

$6,189

n/a

$430,927 $30,082

1Complete conference center information was unavailable due to finances being recorded with other non-conference center related activities (e.g., staff education).

2The Roosevelt Memorial Golf Course has been closed since March 2011; therefore, no income is currently generated. However, maintenance of the grounds still generates some costs.

Source: Institute records

P&L trends cannot be determined for years prior to fiscal year 2012. Prior to fiscal year 2012, the Institute sent all revenue generated from the camp, conference center, and recreation center to the Roosevelt Warm Springs Development Fund (the Fund). During this time, Institute management did not maintain financial records of the revenue-generating activities that would allow for monitoring the profitability of these activities. The Institute had an informal arrangement that the Fund would receive the revenue from these revenue-generating activities and the Fund would either return a portion of the revenue to the Institute for certain expenses or directly pay expenses for the Institute. This practice was stopped by the Institute in late 2011, and funds generated by these activities are now retained by the Institute. This practice appeared to violate the gratuities clause of the Constitution of the State of Georgia which does not allow state entities "to grant any donation or gratuity or to forgive any debt or obligation owing to the public". In addition, there was a lack of internal controls due to Institute management not monitoring the amount of funds transferred to the Fund or having a written contract that detailed the value of the revenue transferred to the Fund in return for the value of services received from the Fund.
RECOMMENDATION The Institute should develop complete P&L statements for each of its revenuegenerating activities. Implementation of this recommendation would enable the Institute to better monitor the financial performance of each activity and make necessary changes to improve each activity's financial performance. In addition, if the Institute wishes to enter into business arrangements with the Fund in the future, it should consult with the Georgia Department of Law to ensure the arrangement complies with the state's laws and regulations.
GVRA Response: The practice of sending some miscellaneous cash receipts to the Institute's Development Fund and the internal control weaknesses did impede our ability to properly capture operating profit or loss. However, all cash receipts are now deposited to State accounts. Additionally, new reporting forms were implemented in FY2013 specifically for conference center activities which provide greater detail into their receipts and disbursements. Also, routine, unannounced cash operations audits are conducted campus-wide by an accounting professional.

Roosevelt Warm Springs Institute for Rehabilitation

30

Appendix A: Objectives, Scope, and Methodology
Objectives
This report examines the Roosevelt Warm Springs Institute for Rehabilitation (the Institute). The Institute was operated as part of the Georgia Department of Labor (GDOL) during the period of our review. However, the Institute was transferred to the Georgia Vocational Rehabilitation Agency (GVRA) in July 2012. Specifically, our audit set out to determine:
1. whether the Institute's Medical Rehabilitation Unit is self-sustaining;
2. the extent to which the residential Vocational Rehabilitation Unit prepares students for employment and independent living;
3. the extent of facility utilization and management; and
4. whether auxiliary programs are self-sustaining.
Scope
This audit generally covered activity related to the Institute that occurred during fiscal years 2009-2012 with consideration of earlier or later periods when relevant. Information used in this report was obtained by reviewing relevant laws, rules, and regulations; interviewing agency officials and staff from GDOL, GVRA, and other state comprehensive rehabilitation centers; and analyzing the Institute's vocational and medical activity data, financial records, and programmatic reports.
The data sets we used to inform multiple audit objectives are described below. We assessed the controls over data used for this examination and determined that the data used were sufficiently reliable for the purposes of our review.
CPSI Data: The Institute's primary information management system is CPSI, which includes admission, discharge, and demographic information for both vocational students and medical patients, as well as patients' medical services and billing information. We obtained CPSI records for all vocational students discharged in fiscal years 2009 through 2011. For the medical unit, we obtained records for all patients served in fiscal years 2009 through 2011.
GDOL Unemployment Wage Data: Many employers must report wages paid to employees to GDOL to determine the amount of unemployment insurance employers must pay and the benefits former employees receive if they become eligible to receive unemployment benefits. We obtained quarterly wage reports from fiscal years 2009 through 2012 for vocational students discharged in fiscal years 2009 through 2011. The records included employer names and wages paid in each quarter.
Georgia Rehabilitation Online Works (GROW) Data: GROW is the case management system used by GVRA's Vocational Rehabilitation (VR) division. Since most of the Institute's vocational students are VR clients, we obtained GROW data for students discharged in fiscal years 2009 through 2011. This data included all cases assigned to the students, including case statuses, the type and cost of services provided, employment dates, employer names, and wage levels.

Roosevelt Warm Springs Institute for Rehabilitation

31

We encountered significant information limitations that affected our scope and audit approach. Since the Institute does not consistently track its students' employment outcomes, we were only able to review outcomes for a recent cohort of Institute graduates using external sources. Also, a lack of detailed financial data for the Institute's medical operations limited our review to two years of financial activity. Last, the Institute does not have adequate records to fully determine the total revenue collected by some of its revenue-generating departments (e.g., camp, conference center). As a result, the extent to which we were able to review the profitability of these activities was limited.
Government auditing standards require we also report the scope of our work on internal control that is significant within the context of the audit objectives. All of our objectives address aspects of the Institute's internal control structure. Specific information related to the scope of our internal control work is described by objective in the methodology section below.
Methodology
To determine whether medical services provided by the Institute are selfsustaining, we obtained the Institute's fiscal year 2010-2012 revenue and expenditures from GDOL. Fiscal year 2013 financial projections were obtained from GVRA. We requested Medical Rehabilitation Unit finances be separated by Inpatient Rehabilitation Facility (IRF), Long Term Acute Care Hospital (LTACH), and Outpatient programs. Using this information we determined whether each medical program's revenue covered its expenditures.
To determine whether the utilization of medical services sustains operations, we used CPSI inpatient activity data to calculate the occupancy rate, average daily census, number of patients served, and number of admissions to the IRF and LTACH in fiscal years 2009-2011. In addition, we used CPSI and Misys15 outpatient activity data to calculate the number of patients served, patient visits, and procedures provided in fiscal years 2009-2011. We also used the financial records and utilization data to estimate the level of services needed to break even with expenditures. We divided each medical program's total expenditures by the average revenue earned per unit of service provided (excluding state funds) to estimate the number of services that need to be provided to cover operations.
It should be noted that we did not assess certain business operations which could impact the medical unit's operating income. These business operations include medical billing rates, collections of patient receivables, and non-acceptance of certain payor types.
To determine the extent to which the Vocational Rehabilitation Unit prepares students for employment, we requested unemployment wage records from GDOL (reported to GDOL by employers) for 601 students discharged in fiscal years 2009 through 2011.16 We calculated the number of students who were employed and earned wages at any point in the first and second years after discharge from the Institute. When unemployment wage records were not available, we used GROW to determine whether the students were employed and earned wages during the first

15 Misys is the information management system used prior to CPSI to manage outpatient activity. 16 We excluded 3 students from this analysis: two for whom we did not have Social Security numbers and one who was a client of another state's VR program.

Roosevelt Warm Springs Institute for Rehabilitation

32

and second years after discharge. GROW also supplied the costs for vocational services that VR provided for students after discharge. We interviewed Institute management and staff to determine methods used to track students' employment outcomes. Deficiencies in internal control related to measuring effectiveness of operations are discussed on pages 17 and 22 of this report.
To assess vocational services, we distributed an email-based survey to VR field counselors. However, completed surveys were received from only 42 of 238 (17.6%) counselors. Due to the low response rate, the information was not used.
Since the vocational program does not systematically track the services it provides to students, we reviewed a sample of 68 student files to identify factors that contribute to student outcomes. The decentralized nature of the data prevented a larger sample review, limiting the analysis we were able to perform.
To determine the extent to which the Institute utilizes and manages its facilities, we obtained Institute facility plans and records, as well as external facility assessments of Institute buildings. We reviewed information from the state's Building, Land and Lease Inventory of Property database. We observed and photographed buildings on the Institute's campus. We also interviewed Institute management and staff regarding building usage and needed repairs.
To determine whether Institute auxiliary programs are operating at a profit or loss, we reviewed available financial records and compared earned revenues (excluding state and federal funds) to expenditures. Complete records were unavailable for the Institute conference center, which limited our review of its profitability. Deficiencies in internal control are discussed on page 29 of this report.
To obtain an understanding of practices at other comprehensive rehabilitation centers (CRCs), we contacted the CRCs operated by seven other states. We interviewed administrators in three states, who provided activity and performance data. Administrators in the remaining states declined to be interviewed, so we were limited to publicly available documentation.
We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Roosevelt Warm Springs Institute for Rehabilitation

State Arkansas3

Comprehensive Rehabilitation
Center
Arkansas Career Training Institute

Appendix B

State Comprehensive Rehabilitation Centers

Administration

Medical

Year Opened

Campus Number of

FY 2011

Size

Buildings Expenditures

(Acres) (Approximate)

Available Medical Services

Medical Services Eligibility

FY 2011 Students Served1

1887-Medical

1961-Vocational4

10

31

$15,337,0365

Outpatient6

Limited to

s tudents

448

Vocational

FY 2011 Completion
Rate

Employment Outcomes (R) = Rehabilitation Rate2 (E) = Graduates' 1st Year
Employment Rate

N/A

N/A

Georgia

Roosevelt Warm Springs Institute for

1927-Medical

940

Rehabilitation

1964-Vocational

72

$36,819,8797

2 inpatient hospitals, 3 outpatient clinics

General public

303

68%

53% (R) 44% (E)

Carl D. Perkins

Kentucky

Vocational Training

1973

17

4

Center

Outpatient, with

General

residential nursing

public

$7,132,004

care option for

(outpatient

523

s tudents

only)

77%

Maryland3

Workforce and Technology Center

1973

21

n/a

Limited to VR

$11,980,898

Outpatient

clients

N/A

N/A

51% (R) N/A

Michigan8

Michigan Career and Technical Institute

1944

72

5

$11,114,884 Minor health services

Limited to s tudents

537

85%

78% (E)

Pennsylvania3

Hiram G. Andrews Center

1959

50

1

Limited to

$22,512,625

Outpatient

s tudents

N/A

N/A

N/A

Outpatient, with

Tennessee3

Tennes s ee Rehabilitation Center

1977

n/a

n/a

$10,458,430 residential attendant Limited to VR

N/A

N/A

clients

N/A

care option

Virginia9

Woodrow Wilson Rehabilitation Center

1947

223

21

Outpatient, with

Limited to VR

$27,775,636 residential nursing

clients

790

83%

care option

70% (R)

1FY11 students served includes only students in vocational training, not those receiving evaluation or participating in other programs.

2The rehabilitation rate is the percentage of all VR cases closed that w ere closed successfully. State VR agencies receiving federal grants have a 55.8% goal. CRC rehabilitation rates represent a subset of the VR population. 3CRC administrators in Arkansas, Maryland, Pennsylvania, and Tennessee declined to be interview ed, so w e w ere limited to information and documents available through state w ebsites. 4In 1887, a military hospital w as opened on the ACTI site, providing medical rehabilitation to soldiers and veterans, and eventually, adult polio patients. The property w as subsequently transferred to the state, w hich introduced vocational rehabilitation programs in 1961. 5Arkansas' expenditures are for federal fiscal year 2011.

6Arkansas' CRC operated a 24-bed acute care hospital for VR clients that w as closed in April 2012 due to low utilization. 7Georgia's expenditures exclude $8,073,005 in dorm construction costs.

8Michigan's information describes their main campus only. MCTI opened a second location in 2010, w hich is not residential. 9Virginia's vocational statistics include occupational skills and life skills training programs. The life skills training program provides independent living and w ork adjustment training over a 9-w eek period.

Source: Interview s w ith CRC management and CRC w ebsites and annual reports

33

Roosevelt Warm Springs Institute for Rehabilitation

34

Appendix C Distribution of IRF Patient Admissions
Fiscal Year 2011

Dade

Catoosa

Walker

Whitfield

Murray

Fannin

Gilmer

Chattooga Floyd

Gordon Bartow

Pickens Cherokee

Union

Towns

Rabun

Lumpkin

White

Dawson Hall

Habersham Stephens

Banks

Franklin

Forsyth

Jackson

Madison

Hart Elbert

0 admissions 1-2 admissions 3-5 admissions 6-9 admissions
Institute IRF

10-19 admissions 20-49 admissions 50-75 admissions Location of other IRFs

Polk Haralson

Paulding

Cobb

Douglas

Gwinnett Dekalb

Barrow

Clarke Oconee

Walton

Oglethorpe

Wilkes

Lincoln

Rockdale

Carroll

Fulton

Clayton

Newton

Morgan

Greene

Taliaferro

McDuffie Columbia

Heard

Coweta

Fayette

Henry

Spalding

Butts

Jasper

Putnam

Warren

Hancock

Glascock

Richmond

Troup

Meriwether

Pike

Lamar

Monroe

Jones

Baldwin

Washington

Jefferson

Burke

Harris

Upson Talbot

Crawford

Bibb

Wilkinson

Twiggs

Johnson

Jenkins

Screven

Muscogee Chattahoochee

Taylor

Marion Schley

Macon

Peach

Houston

Bleckley

Pulaski

Dodge

Stewart

Webster

Sumter

Quitman

Randolph

Terrell

Lee

Clay

Calhoun

Dougherty

Early

Baker

Miller

Mitchell

Dooly Crisp

Wilcox

Turner

Ben Hill

Irwin Tift

Worth

Colquitt

Berrien Cook

Laurens

Emanuel

Treutlen

Candler

Bulloch

Effingham

Montgomery

Wheeler

Toombs

Evans

Telfair

Jeff Davis

Coffee

Appling Bacon

Tattnall Long
Wayne

Atkinson

Pierce

Ware

Brantley

Bryan

Chatham

Liberty McIntosh Glynn

Seminole

Decatur

Grady

Thomas

Brooks

Lanier

Lowndes

Clinch Echols

Charlton

Camden

Note: 12 admission records were missing the patient's county of residence Source: Institute patient records and IRF websites

Roosevelt Warm Springs Institute for Rehabilitation

35

Appendix C (continued) Distribution of LTACH Patient Admissions
Fiscal Year 2011

Dade

Catoosa

Walker

Whitfield

Murray

Chattooga Floyd

Gordon Bartow

Fannin

Union

Gilmer Pickens

Lumpkin Dawson

Cherokee

Forsyth

Towns

Rabun

White

Habersham Stephens

Banks

Franklin

Hall

Jackson

Madison

Hart Elbert

0 admissions 1-2 admissions 3-5 admissions 6-9 admissions
Institute LTACH

Polk Haralson

Paulding

Cobb

Douglas

Gwinnett Dekalb

Barrow

Clarke Oconee

Walton

Oglethorpe

Wilkes

Lincoln

Rockdale

Carroll

Fulton

Clayton

Newton

Morgan

Greene

Taliaferro

McDuffie Columbia

Heard

Coweta

Fayette

Henry

Spalding

Butts

Jasper

Putnam

Warren

Hancock

Glascock

Richmond

Troup

Meriwether

Pike

Lamar

Monroe

Jones

Baldwin

Washington

Jefferson

Burke

10-19 admissions 20-30 admissions
Location of other LTACHS

Harris

Upson Talbot

Crawford

Bibb

Wilkinson

Twiggs

Johnson

Jenkins

Screven

Muscogee Chattahoochee

Taylor

Marion Schley

Macon

Peach

Houston

Bleckley

Pulaski

Dodge

Stewart

Webster

Sumter

Quitman

Randolph

Terrell

Lee

Clay

Calhoun

Dougherty

Early

Baker

Miller

Mitchell

Dooly Crisp

Wilcox

Turner

Ben Hill

Irwin Tift

Worth

Colquitt

Berrien Cook

Laurens

Emanuel

Treutlen

Candler

Bulloch

Effingham

Montgomery

Wheeler

Toombs

Evans

Telfair

Jeff Davis

Coffee

Appling Bacon

Tattnall Long
Wayne

Atkinson

Pierce

Ware

Brantley

Bryan

Chatham

Liberty McIntosh Glynn

Seminole

Decatur

Grady

Thomas

Brooks

Lanier

Lowndes

Clinch Echols

Charlton

Camden

Note: 5 admission records were missing the patient's county of residence Source: Institute patient records and LTACH websites

Roosevelt Warm Springs Institute for Rehabilitation

36

Appendix D Skills Training Programs1

Arkansas Georgia Kentucky Maryland Michigan Pennsylvania Tennessee Virginia2 Total

Auto Mechanic

X

Auto Detailing/

Tires and Lubrication

X

X

X

X

X

X

5

X

X

4

Auto Part Sales

X

X

2

Building Maintenance

X

X

X

X

4

Business Education3/

X

X

X

X

X

X

Customer Service

X

X

8

Cabinetm aking

X

X

2

Childcare

X

X

2

CNA/Health Aide

X

X

X

X

X

5

Cons truction

X

X

X

3

Cos m etology

X

Culinary Arts/

Food Service

X

Cus todial/

Hous ekeeping

X

X

X

X

X

X

X

X

X

2

X

X

7

X

5

Drafting

X

X

2

Electronics

Equipment and Small

Engine Repair

X

X

1

X

2

Grounds keeping

X

X

X

X

4

Machine Technology

X

1

Materials Management/

X

X

X

X

Warehous e

Medical Assistant or

Technician

X

X

X

X

X

6

3

Office Automation

X

1

Printing

X

X

X

3

Retail Marketing and

X

Sales

X

X

X

4

Security Guard

X

1

Telecom m unications

X

X

X

3

Weatherization

X

1

Welding

X

1

Total

14

4

9

10

15

12

8

10

1Some CRCs have programs that encompass more than one area (e.g., building maintenance may include groundskeeping). For these programs, both

areas of study are noted here.

2Virginia also offers an "External Training Option," w hich provides customized training in a field chosen by the student.

3Business education includes training on basic computer softw are.

Source: CRC w ebsites

The Performance Audit Division was established in 1971 to conduct in-depth reviews of state-funded programs. Our reviews determine if programs are meeting goals and objectives; measure program results and effectiveness; identify alternate methods to meet goals; evaluate efficiency of resource allocation; assess compliance with laws and regulations; and provide credible management information to decision-makers. For more information, contact
us at (404)657-5220 or visit our website at www.audits.ga.gov.