Audit of the Department of Mental Health Objectives, Scope, and Methodology

An overview of the purpose and process of auditing the Department of Mental Health.

Overview

In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of the Department of Mental Health (DMH) for the period July 1, 2016 through September 30, 2018.

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.

Below is our audit objective, indicating the question we intended our audit to answer, the conclusion we reached regarding the objective, and where the objective is discussed in the audit findings.

Objective	Conclusion
Are clinically stable clients discharged in a timely manner to less restrictive environments?	No; see Findings 1 and 2

 

To achieve our objectives, we gained an understanding of DMH’s internal control environment related to our audit objectives by reviewing applicable laws, regulations, and agency policies and procedures, as well as conducting inquiries and performing site visits with DMH’s staff and management.

We performed the following procedures to obtain sufficient, appropriate audit evidence to address the audit objective.

• We reviewed Joint Commission⁴ reports for each DMH-funded facility to assess whether there were risks associated with client discharge.
• We met with area directors to identify their responsibilities in providing oversight of the treatment of continuous care clients to prepare them for discharge.
• We interviewed a DMH official to understand what factors DMH considers barriers to timely client discharge.
• We inspected case files using a random nonstatistical sample of 67 out of a population of 803 records of clients who received treatment for 30 days to five years after admission and whose discharge dates were no later than September 30, 2018. We performed the following procedures:
  - DMH management has set a goal of discharging clients within 30 days of their anticipated discharge dates. To determine discharge timeliness, we took a conservative approach and used 60 days to factor in barriers such as housing placement or community program availability. We computed the number of days from the anticipated discharge date to the actual discharge date.
  - We inspected the Social Work Discharge Summary, Patient Referral Form, or Clinical Social Work Form⁵ for each of the records in our sample to verify that each case file contained the placement location and any relevant notes.
  - We inspected client release forms to assess whether clients or legal representatives signed them to consent to the discharge. In situations where clients or legal representatives refused to sign, we assessed whether DMH included the reason in the case file.
  - We inspected the Social Work Discharge Summary or the Clinical Social Work Form to verify that DMH assigned a case manager to each client’s case.

Data Reliability

We reviewed the DMH Information Security Handbook and interviewed DMH information technology personnel to assess the management controls of the Mental Health Information System (MHIS), a customized version of the Meditech company’s Health Care Information System containing patient medical records.

We performed a data reliability assessment to verify the completeness, accuracy, and reliability of MHIS as it relates to patient case files. We obtained information through MHIS and reviewed the Structured Query Language⁶ query documentation to ensure that all records and requested fields were included in the received data. Additionally, we tested the data files to make sure that there were no duplicates; that there were no records with discharge dates after September 30, 2018; and that key fields had the appropriate data with no blank fields. We also took a sample of original source documents; reviewed the values in key data fields of the MHIS data files; and made sure that the fields for patient identification number, date of admission, facility name, and legal status in the original source documents matched the values in MHIS. We reviewed information system access controls that were in place from July 1, 2016 through June 30, 2018 for 20 out of 337 employees terminated during that period. We determined that the data were sufficiently reliable for the purposes of the report.

4.    The Joint Commission, a nationally recognized independent, not-for-profit organization, accredits all DMH facilities. Joint Commission certification reflects a hospital’s commitment to meeting the performance standards in the commission’s Comprehensive Accreditation Manual for Hospitals. All DMH hospitals are surveyed and accredited every three years.

5.    The Social Work Discharge Summary is owned by DMH, whereas the Clinical Social Work Form is owned by the Department of Public Health. The forms are nearly identical and are used for the same purpose. The form used depends on the hospital where the patient received care.

6.    Structured Query Language is used to communicate with the MHIS database.

Date published:	August 1, 2019