Dianna Phillips, Executive Director

June 30, 2016

Williamson-Burnet County Opportunities, Inc.

604 High Tech Dr.

Georgetown, TX 78626

RE: FY 2016 Contract Monitoring Report

Dear Ms. Phillips:

Enclosed for your files is the narrative report of the monitoring conducted on June 1-3, 2016 by the AAA staff. At the completion of the monitoring at the Administrative Office an exit conference was conducted to present the compliance summary and identify areas of non-compliance.

The AAA staff thanks you and your team for being very responsive and helpful during the monitoring visit. It should be noted that although there are areas of concern, it is recognized that the WBCO team is putting in a tremendous amount effort and we continue to see improvement and growth throughout the team. It should also be recognized that the monitoring was a much smoother process this year than last year, because of the improved organizational level of records.

If you have questions, please call me at 512-916-6053.

Respectfully,

Jennifer Scott

Director of Aging Services

Enclosure(s) Narrative Reports

cc: Lori Steiner, CFO

Karen Lester, Board Chair

Denise Schilli, Nutrition Program Director

NARRATIVE REPORT: FISCAL

AAA Staff conducted a desk review for fiscal monitoring of WBCO. Expenditures, program income, and local cash reported were reviewed for the months of November 2015 and December 2015. AAA staff also reviewed closeout FY2015 fiscal data for reconciliation. Written policies and procedures were also reviewed to ensure adequate internal controls and proper handling and controls of funds.

LEVEL 1 SANCTION #1: ACCOUNTABILITY (PROGRAM INCOME)

Statement of Revenue and Expenses and Expanded GL provided for November and December 2015did not reconcile to the RFR. Internal documentation had higher amounts received. RFRs were corrected for both months but not yet submitted to AAACAP. This is the second consecutive year that Program Income could not reconciled to submitted RFRs.

Completion due date: August 3, 2016:

Submit restated RFRs from October 2015 to May 2016, these were received with changes including May 2016. Back up detail below is required.
Submit GL Entries for PI for October 2015 to May 2016 to demonstrate that the PI totals submitted in post monitoring months are reconciled.

Citation:40 TAC §85.201 (d) (1) (A) (D)

RESPONSE:

LEVEL 1 SANCTION #2: ACCOUNTABILITY (POLICY MANUALS)

For the third year in a row, policy manuals, training manuals, and individual supplied materials during the monitoring noted conflicting information between manuals, site locations, site leader manuals, and other areas of documentation.

Completion due date: August 3, 2016:

Provide a POC which demonstrates a consistent method of ensuring that all the information in all the documents match and is consistent.
Provide a POC that includes an ongoing process for keeping all information current; replacing old information with new information in all manuals and locations.

Citation:40 TAC §85.201 (d) (1) (A) (D)

RESPONSE:

FINDING #1: Data Use Agreement (DUA) COMPLIANCE

There is a lack of substantial procedure and staff training for the protection of protected health information (PHI) while stored and transmitted electronically, as per the requirements of the Data Use Agreement (DUA). Additionally, there were significant issues with data integrity and data loss prevention, as file libraries were significantly compromised by a former high-level employee who was able to access and remove or delete all relevant files from her computer immediately prior to termination / separation from the organization, without leaving any backups. Paper backups were additionally at risk of compromise due to flood damage at the main office incurred by nearby construction. A secured e-mail platform was not in place for transmitting PHI, such as rosters, in a secured format.

Completion due date: August 3, 2016:

Create, submit to the AAA, and implement procedures to maintain client confidentiality in regards to storing and transmitting electronic files, including implementation of a secure (encrypted) e-mail system.
Ensure policy is in place to maintain data safety and integrity upon employee termination / separation from employment.
Institute robust data backup procedures to prevent loss of data in case of physical or electronic compromise.

Citation:40 TAC§85.201 (d)(1)(B) / 40 TAC§85.201 (h)(2)(B)

RESPONSE:

Concerns are items that if not corrected or revised could result in a finding in later on-site monitoring visits.

CONCERN #1: EMERGENCY DISASTER PLAN

Emergency / Disaster Procedures refer to an Extended Disaster Plan for details on emergency closure procedures. These procedures are not covered in detail in that section of the Policies and Procedures, but rather, describe first-response reactions to specific disaster types, rather than enumerating a specific plan of action in the event of site closures. It is suggested that the P&P that details a specific extended plan of action in case of site closures, and ensure this is included in the Extended Disaster Plan, if both documents will continue to be utilized.

Citation: 40 TAC §85.201 (x)(2)(A)(B) / 40 TAC §85.302 (u)

CONCERN #2: SECTARIAN INVOLVEMENT POLICY

Sectarian involvement policy was omitted from recently used policy and training manuals. This policy was located in a manual from 2012 but had been removed since then. Update all policy manuals to reflect non-involvement in religious or anti-religious activity as required by the TAC.

Citation:40 TAC §85.302 (s) (1) (2) / 40 TAC §85.309 (e) (1) (2)

CONCERN #3: OUTREACH

Outreach plan does not specifically state targeting for clients with Alzheimer’s or other neurological disorders.Update outreach plan to ensure all targeting criteria, per the Older American
Act and the contract directs.

Citation:40 TAC 85.201 (f)(1) / 40 TAC 85.302 (p) / OAA §306 (a)

CONCERN #4: EMPLOYEE TRAINING

There is a lack of documentation of new employees receiving the amounts of training required by the TAC. Provider could not supply training logs that identify the specific topics required by TAC to be trained upon hire or designated time frame(s). Provider did provided a statement by each employee that they were trained. Ensure that required trainings and the appropriate amount of training is provided to all new employees in a timely manner and documented as required by the TAC.

Citation: 40 TAC §85.302 (o)

NARRATIVE REPORT: NUTRITION AND SENIOR CENTER OPERATIONS

The monitoring of congregate meal service was conducted on June 2, 2016 at the Seriff Center (Marble Falls). Present during the visit were the site leader and staff. The menus were posted and adequate temperatures were recorded. The facility was clean and orderly, policies and procedures were reviewed, fire drills were documented and fire extinguishers had current inspections. The congregate meal service was observed and temperatures were taken by the facility staff during monitoring. The Health and Safety Inspection and a copy of the current Fire/Safety inspections for this site were reviewed. Documentation of CPR, First Aid certification, and Food Managers Certification are maintained at the nutrition site. The process of distributing meals to Burnet for Home Delivered Meal routes was also reviewed, and a Home Delivered Meal route was monitored there. Despite widespread, extremely inclement weather (including roads closed by flooding), food was delivered to clients in a timely manner, with food temperatures maintained within appropriate parameters, by a highly motivated and friendly group of staff and volunteers.

CONCERN #1: The most recent kitchen health inspection could not be located; while the facility is operated by the Boys and Girls Club of Marble Falls, this information should be made available to WBCO and a copy retained for WBCO’s records. Maintain all record of attempts to obtain the health inspection and supply the report to the AAA once received.

Citation:40 TAC §85.201 (m) / 40 TAC §85.302 (c) (2)

CONCERN #2: Signage pertaining to contributions needs to be updated to reflect that client contributions are voluntary.

Citation:40 TAC 85.201 (l)(1-2) / AAA-PI 304 / CFR Part 45 §1321.67 (1)

CONCERN #3: Postings of available services and AAA contact information were generally outdated and in need of replacement.

Citation:40 TAC 85.201 (u)

NARRATIVE REPORT: NUTRITION AND SENIOR CENTER OPERATIONS CONT.

The monitoring of the Madella Hilliard Senior Center (Georgetown) was conducted on June 3, 2015. Present during the visit was the Site Leader and staff. The facility was clean and orderly, policies and procedures were reviewed, and fire drills were documented. Fire extinguishers were up to date on inspections, and food temps were well documented as well as internal quality control measures. The Health and Safety inspection and a copy of the current Fire/Safety inspections for this site were reviewed and were in compliance. Documentation of CPR, First Aid certification, and Food Management Certification are maintained at the nutrition site.

FINDING #1: COMPLAINT / GRIEVANCE PROCEDURES: Complaint logs lack a date of resolution as required by the TAC.

Completion due date: August 3, 2016:

Update and submit complaint log template to include specific information required by the TAC.

Citation: 40 TAC §81.19 (b)(1)(B) / (c)(1,3) / 40 TAC §85.201 (dd) (4-6) / 40 TAC §85.302 (c)

RESPONSE:

CONCERN #1: Signage is posted too high. Postings of available services and AAA contact information were generally outdated and in need of replacement. When posting information for consumers, ensure the height placement and the font of the information can be easily read by seniors and those with disabilities (i.e. wheelchair-bound clients).

Citation:40 TAC §85.309 (c) (1) / Americans with Disabilities Act

CONCERN #2: Fire drills were being performed semiannually instead of quarterly. Fire drill forms lacked documentation of outcome of drill / issues / suggestions for improvement. Develop a plan to ensure fire drills are conducted quarterly as required.

Citation:40 TAC §85.309 (c) (1) / Americans with Disabilities Act

WBCO-OM-June 1-3, 2016 –Rpt. of finding 7/1/16