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									                                                                                          BOARD OF COMMISSIONERS
                                                                                    J EFFREY T. H ASTE, CHAIRMAN

DAUPHIN                                                                             DOMINIC D. DIFRANCESCO II, VICE CHAIRMAN
                                                                                    GEORGE P. H ARTWICK III, SECRETARY

   COUNTY                                                                               CHIEF CLERK/CHIEF OF STAFF
                                                                                    CHAD SAYLOR
        DEPARTMENT OF HUMAN SERVICES                                                DIRECTOR OF HUMAN SERVICES
        MENTAL HEALTH - MENTAL                                                      SANDY M OORE, MSW
        RETARDATION PROGRAM                                                         HUMAN SERVICES SOLICITOR
               100 CHESTNUT STREET, 1ST FLOOR                                       FREDRICK W. LIGHTY, ESQUIRE
              H ARRISBURG , PA 17101                                                    MH/MR ADMINISTRATOR
              (717) 780-7050
              (717) 780-7061 FAX
                                                                                    DANIEL E. EISENHAUER

 June 15, 2007

 Mr. Kevin Casey, Deputy Secretary
 Office Of Developmental Programs
 P.O. Box 2675
 Harrisburg, PA 17105-2675

 Dear Mr. Casey:

 On behalf of the Dauphin County Mental Health and Mental Retardation Program, we are pleased to
 submit the Mental Retardation Plan for fiscal year 2008-2009. Through the proposals included in this
 plan, we are prepared to enhance or initiate services for individuals who are now waiting for services.

 Thank you for the opportunity to present this information about the needs of our citizens and these
 funding requests. The annual planning process presents an important opportunity to provide an update on
 Dauphin County’s current capacity and challenges in service delivery. We are looking forward to a
 continued cooperative relationship with the Department of Public Welfare in order to eliminate the
 waiting list for mental retardation services.

 A Plan hearing was held on May 31, 2007 to publicly review the contents of the Plan. The MH/MR
 Board endorsed the Plan at the conclusion of the hearing. Additionally, the MR Committee of the Board
 was involved in the plan review and holds quarterly public forums for consumers and families to express
 their ongoing opinions, needs, and concerns.


 Jeffrey T. Haste                                     Daniel E. Eisenhauer
 Commissioner – Chairman                              MH/MR Administrator

 Dominic D. DiFrancesco II                           Chad Saylor
 Commissioner - Vice Chairman                        Chief Clerk

 George P. Hartwick III
 Commissioner - Secretary

         For the Plan Year


            Stage I

                         June 15, 2007
                  Request for Administrative Funding
   Current Administrative Structure
   The Dauphin County Mental Health/ Mental Retardation Program is located at 100
   Chestnut Street, Harrisburg, PA 17101. This is the administrative office, from which
   the county program administers a system of mental retardation services and supports
   available for citizens with intellectual disabilities. These services have been designed
   to meet the needs of local citizens with intellectual disabilities, and to support their
   families and caregivers. Over the past 40 years, our community system has been
   developed with the belief that individuals with intellectual disabilities should be able
   to receive the services and supports they need in their home communities and should
   be able to enjoy the same quality of life as any other citizen. Dauphin County has
   been in the forefront of the recent move towards increased consumer empowerment
   and control in decision-making about services. Through our Self Determination
   Initiative and through the extensive use of person-centered planning for services and
   supports, our services have become increasingly more inclusive, effective, and
   targeted to meet each individual’s unique needs.

   Under the MH/MR Act of 1966 the County Commissioners are the local authority
   responsible for planning and arranging an array of services at the local level to meet
   the needs of citizens who have intellectual disabilities. These required services are
   assigned to the Human Services Department where they are managed by the MH/MR
   Administrator and staff. An MH/MR Board made up of local citizens is appointed by
   the county commissioners to advise the commissioners regarding the MH/MR
   Program. The Mental Retardation Committee of the Board is responsible for ongoing
   oversight of mental retardation services. The membership of the MH/MR Advisory
   Board and the MR Committee, which focuses on issues specific to Dauphin County’s
   services to people with a label of mental retardation, includes individuals with
   disabilities and family members.

   Service Coordination Services: Dauphin County has one central point of intake and
   referral. We contract for BSU services with the CMU, a private, non-profit agency.
   Over 2,000 individuals with mental retardation and infants/toddlers with early
   intervention needs are served each year. The CMU is located at 1100 South Cameron
   Street in Harrisburg and also maintains an Upper Dauphin office. The Mental
   Retardation/Early Intervention Unit employs approximately 45 staff. On any given
   day, the Mental Retardation/Early Intervention Unit service/supports coordination
   caseload is over 1,600 individuals. Over half of these registered individuals are
   children living at home with their families.

   Individualized Planning: The first step into the system is the intake and eligibility
   determination process through the CMU. Every new person who requests service is
   screened through an eligibility determination process and their need for service is
   formally assessed. If eligible, a supports coordinator is assigned to assist in planning,
   referral, coordination, and monitoring services. Each person who is served has an
   Individual Support Plan (ISP) that includes a person-centered and comprehensive

Dauphin County MR Annual Plan FY 08/09       1
   information gathering and service planning process. Included in this process is a
   Prioritization of Urgency of Need for Services (PUNS). Unmet needs identified
   through the PUNS process are recorded in a waiting list database - HCSIS. Each
   individual is also informed of his or her rights for accessing an appeal process.

   Service Provision: All mental retardation services in Dauphin County are provided
   through contracts with private agencies or individuals. Dauphin County has contracts
   with two agencies that act as Intermediary Service Organizations (ISO’s) or ―payment
   agents‖ so that individuals can exercise choice by hiring their own staff or the
   purchasing of specialty items or renovations. During July 2007, the Office of
   Developmental Programs will contract with a statewide provider for these services.
   Individuals currently receiving this service will transfer to the state’s ISO by January
   of 2008. Dauphin County currently manages approximately 50 mental retardation
   service contracts, totaling over $40 million in services. The majority of these funds
   are federal Medicaid Waiver funds received through an annual allocation process
   from the Pennsylvania Department of Public Welfare, Office of Developmental
   Programs. A small amount of base funding is available for support coordination,
   county administration, family support services, and other needed services not funded
   by the waiver.

   Dauphin County has cultivated an extensive network of local agencies and
   individuals available to provide a variety of services and supports. The MH/MR
   Administrator’s office strives to maintain a positive and mutually beneficial
   relationship with our service providers in a challenging, ever-changing, and
   increasingly difficult funding and regulatory environment. Five large service
   providers and several smaller agencies offer residential services. Residential services
   are core services, costing the most, and often lasting for a lifetime. These services
   include Intermediate Care Facilities for the Mentally Retarded (ICF/MR’s), group
   homes, family living homes (now referred to as Life Sharing) and supported
   apartment living. There are over 70 licensed sites in Dauphin County serving close to
   400 individuals. Other licensed mental retardation programs include 7 Adult
   Developmental Training day program sites and the purchase of services from four
   Facility Based Vocational Training programs. Two of these are located in contiguous
   counties. Currently there are seven contracted providers for home-based community
   habilitation, which generally involves providing staff support in a family’s own

   Currently there are approximately 400 individuals being served through the
   Consolidated Home and Community Based Waiver funding stream and about 190
   individuals receiving Person and Family Directed Support Waiver services. Close to
   300 infants and toddlers are receiving Early Intervention services on any given day.
   More than 400 individuals continue to receive Base (90% State, 10% County) funded
   Family Support Services.

Dauphin County MR Annual Plan FY 08/09      2
                     Request for additional administrative personnel
   Four full-time, mental retardation professionals, as well as an Early Intervention
   Coordinator staff the Mental Retardation Department at this time. The County office
   has remained at this level of staffing for the past few years. As the Administrative
   Entity (AE), the county office has acquired additional administrative responsibilities
   pursuant to the Administrative Entity Operating Agreement. The county office is
   requesting one additional staff to provide enhanced focus to a number of important
   new functions of the county office:
       1. Activities to ensure that all providers with a standard contract with the AE for
           waiver services meet the qualification standards as outlined in the approved
       2. Monitoring of all assigned fiscal and program administrative services.
       3. Conducting an annual administrative review of the services provided using the
           procedures determined by the Office of Developmental Programs.
       4. Activities to provide enhanced focus on enhancing employment
           services/supports to the persons served by the mental retardation system.

The budget request for this position is $75,000.

Dauphin County MR Annual Plan FY 08/09      3
                              Efforts for Expansion
1. Service/Supports Coordination
The CMU is our Supports Coordination Unit. For the past few years, we have requested
dollars for hiring additional Supports Coordinators. At the core of all the work we do is
that of arranging for appropriate and ongoing supports to assist people in living
meaningful lives — services that allow them to live safely and healthy in our community.
The work that occurs between the person, the people who care about that person and their
Supports Coordinator is at the core of this relationship.

                   Request for One (1) Supports Coordination Supervisor
CMU added five Supports Coordinators to its complement during FY 2006-2007. This
represented a significant enhancement of our ability to provide quality service and
increase the customer service attention for the individuals and families in our service.
The addition of five Supports Coordinators increases the total from 23 to 28 Supports
Coordinators. These additions reduced the aggregate caseload number by ten individuals
per Supports Coordinator, a significant improvement in our system’s capacity to provide
quality Supports Coordination services. CMU has embarked on a reorganization of its
mental retardation service area to incorporate the five new Supports Coordinator
positions in a manner that maximizes the benefit across the program and also spreads the
increased supervisory workload among the three existing Supports Coordinator
Supervisors as evenly as possible.

In order to continue building upon quality, we request support to add a fourth Supports
Coordination Supervisor. This will enhance our ability to provide solid supervisory
support and oversight for our Supports Coordination staff. With the increase in our
Supports Coordination complement, our Supervisor: Supports Coordinator ratio is 1:9 in
two programs and 1:10 in the third. A fourth Supervisor would result in a ratio of 1:7.
This addition would enable us to provide much more effective supervision and quality

The budget request for this position is $72,000.

           Request for Supports Coordination Quality Assurance Assistant
CMU proposes adding a position that would be classified as Clerk-Typist III and that
would serve to support and assist the mental retardation service area with both data entry
and quality management support needs. This position will include the ability to assist
management staff of the program with data review and integrity activities required in
order to assure Administrative Entity continuous evidence based performance compliance
needs. Proposed activities that would be supported by this position would include:
             Data entering and tracking of the ISP signature sheet, once plan is
                approved and entering services in plans.
             IM4Q sampling and sampling for chart audits.
             Demographics data integrity. Demographic corrections, changes, and
                maintenance activities.

Dauphin County MR Annual Plan FY 08/09      4
              Assisting supervisors in the tracking of monitoring for individual in
               service by Supports Coordinators.
              Assisting with the Administrative Entity Continuous Evidence Based
               Oversight process by reviewing information and identifying and/or
               making corrections to the data if it is incorrect.

The addition of the Supports Coordination Quality Assurance Assistant would enable the
management staff to concentrate more of their time and energy on management activities.
This would significantly reduce the amount of time they must currently allocate to
clerical functions related to data integrity.

The budget request for this position is 48,000.

Dauphin County MR Annual Plan FY 08/09      5
The directions for the Plan Year 2008-2009 planning process direct the County to focus
on the needs for services and supports identified through the PUNS extract of April 13,
2007 for persons who are in the emergency or critical need categories. Even though it is
recognized that by the time funding resulting from this plan would be received in FY
2008-2009 many of the individual’s needs will have been met or changed, history tells us
that at least this number of individuals will need similar services. There are also several
priority groups that we are asked to address through the planning process, such as recent
graduates/‖aging out‖ of high school services and services to persons aging out of
EPSDT services. In addition, the County must take into consideration local capacity for
service development, resources, and infrastructure, so that requests for expansion are
realistic and deliverable. We are fortunate to have an excellent supports coordination unit
and able provider agencies still willing to provide the needed services, even in these
challenging times.

2. Waiting List – Person/Family Directed Supports Waiver
Service expansion requests for fiscal year 2008-2009 include requests to serve all un-
served persons in emergency status on the PUNS. In addition, there are 11 young adults
who will graduate in June 2008. Some of these students will need supports to maintain
employment and other supports to lead active lives in the community. Typically these
individuals are asking for day programs, individualized supports, vocational training, job
coaching, and transportation. Some of them have respite or other individualized support
or therapy needs as well. We are proposing to serve all of these transition individuals to
give them a good start in their adult life.

The county is enhancing its emphasis to support individuals in locating and maintaining
employment. See ―Strategies to promote employment,‖ page 8.

The total request of funds through the Person/Family Directed Supports Waiver is
1,500,000 to serve approximately 35 individuals.

3. Waiting List – Consolidated Waiver
As mentioned above, we have 11 students graduating from high school in June 2008. A
number of these young adults are requesting residential supports. It would be our
intention to support these young adults in life sharing situations or to move existing
people into life sharing and utilize residential service openings. We anticipate that at
least 6 of those students will need residential supports. It is anticipated that we will need
an additional 6 residential supports (life sharing, residential programming) for this group
of young adults. The first consideration will be a Life Sharing situation. If the young
adult needs a group living arrangement, then the county will work to identify a person
living in a residential program interested in moving to a Life Sharing arrangement and
result in an opening in our residential system.

One of the individuals we are proposing to serve is a person who currently resides in a
State Center. Both this person and his family are requesting that he move to the
community. Because of his specialized physical needs we are proposing to serve this
person in an individualized setting with intensive supports, at least initially. An extensive

Dauphin County MR Annual Plan FY 08/09        6
person-centered planning process will be used, taking into consideration the person’s
safety and health needs. The proposed cost of serving this person is $600,000 that is
included in the Consolidated Waiver total.

Dauphin County is also requesting Consolidated Waiver funding to serve the remaining
un-served or underserved persons on the Emergency PUNS waiting list. The services
requested include various levels of residential care, employment and day programs,
therapies, individual supports, and transportation.

The cost to provide all of the needed consolidated waiver services for approximately
40 individuals will be $5,000,000.

4. Services to persons “aging out” of current placement
We propose to serve one teenager who currently resides in a residential treatment facility
who is requesting to return to Dauphin County. The projected cost is $295,000.

The total request for all of the expansion described above in the Dauphin County Mental
Retardation System is $6,990,000. It should be noted that while this request is a
significant increase, it by no means addresses the needs of all of the individuals who need
additional services, nor does this increase eliminate the need for a waiting list for
                                 Summary of Funding Request

           County Administration                                         75,000
           Supports Coordination Expansion                              120,000
           P/FDS                                                      1,500,000
           Consolidated Waiver                                        5,000,000
           Age Out                                                      295,000
           Total Request                                              6,990,000

Should the above described addition funding become available, Dauphin County is
confident that our Mental Retardation System would be able to provide the needed
supports and services.

Dauphin County MR Annual Plan FY 08/09       7
                            Priority Planning Areas
                          Integrated children’s planning activities
   In Dauphin County, all of the Human Service agencies work closely together under
   the auspices of the County Human Services Director’s Office. We conduct cross-
   system training and have an ongoing process of sharing issues and needs through a
   regular meeting of the Children’s Directors. The MR Department, CMU, and our
   Children and Youth agency supervisors meet to coordinate services for the children
   who are under the responsibility of Children and Youth and also have or need a
   supports coordinator. This is especially important in planning for young people who
   will be aging out of the Children and Youth System.

   The MR Department is very active in C&Y’s System of Care Grant. The Deputy MR
   Administrator serves on the System of Care Implementation Team and we have
   participated in the recent planning process of this team.

                              Strategies to promote employment
   The Mental Retardation System works closely with other human service delivery
   systems such as the Mental Health System, Children and Youth Services, and the
   Office of Vocational Rehabilitation. Transition planning is an important focus with
   the local school districts. The CMU participates in a local Transition Coordinating
   Council (TCARS). Supports Coordinators maintain close linkages with local school
   districts and participate in IEP meetings and transition planning whenever possible.
   There has also been an effort in recent years to learn more about the community and
   to assist individuals to find generic resources available in the community to meet
   some of their needs. Recently the Office of Developmental Programs developed an
   initiative to focus on employment outcomes. The goal is to support as many
   individuals as possible to achieve competitive employment rather than spending many
   years in segregated, sheltered settings.

   Dauphin County serves as one of the initiative counties. The employment initiative’s
   goal is to promote competitive employment opportunities for consumers with mental
   retardation. Dauphin County strives to utilize all competitive employment
   opportunities available to achieve this goal. Dauphin County will strive to improve
   outcomes for those who have not yet achieved their desired goals. Our specific
   strategies to increase focus on competitive employment include:

   1. Provide education and information to Supports Coordinators and Residential and
      other staff to understand the knowledge that informs effective and best practices
      for employment services.
   2. Develop a good working relationship with the Office of Vocational Rehabilitation
      as well as our providers who support employment.
   3. Support the work of the Employment Council to identify barriers in information
      and service delivery – including the design of a ―Consumer support culture‖ and
      identify collaborative relationships in the community with potential employers

Dauphin County MR Annual Plan FY 08/09     8
      and employment support agencies. (CAIU- high schools, community colleges,
      OVR, benefits counselors).
   4. Develop a data tracking system to track key data for individuals that are seeking
      competitive employment opportunities and our progress in the Dauphin County
      Mental Retardation System. The data will be shared with the Office of
      Developmental Programs on an annual basis.

                              Strategies to promote Life Sharing
Dauphin County has always and continues to support the Life Sharing model as the most
desirable type of residential program for people. We not only support Life Sharing as the
most supportive and least restrictive 24-hour residential program but also continue to
aggressively work to develop new Life Sharing opportunities for the citizens that we
serve. We feel that the growth in providing these opportunities ongoing and particularly
over the past three years has kept Dauphin County in the forefront of expansion of this
very desirable and financially prudent residential option for individuals.

The Dauphin County MH/MR Program currently has 51 individuals in Life Sharing home
placements. This constitutes close to 20% of all 24-hour residential programs in the
County. Dauphin County is currently planning the initiation of two additional Life
Sharing opportunities over the next two months. Our objective is to continue growth of
Life Sharing in Dauphin County and to provide as many opportunities as possible to
allow individuals to have a home and a family to share their life with.

Despite our desire and work to continue growth of life sharing there are challenges to the
development of these programs. Of course funding is a continuing challenge. Despite
the financial advantage of Life Sharing it remains difficult to find the dollars for
development in the limited expansion of our annual budget. A second challenge for all
Life Sharing development is the match of the right family for the right consumer. This
has always been a challenge and thoughtful planning has been an advantage that has
allowed Dauphin County continued success in Life Sharing development. Many
individuals moving into Life Sharing settings come from placements in existing group
homes. This reality can create issues when a Life Sharing match becomes a struggle after
some time of success and the need for the individual to move from the home.
Unfortunately on many occasions another has taken the individual’s group home
placement individual and thus another residential program must again be found for the
individual of the failed arrangement.

These challenges are not new and will not deter Dauphin County from our continued
expansion and support of Life-sharing for any individual in Dauphin County that desires
a home with a Life-sharing family. Strategies to support Life Sharing include:

   1. As the Dauphin County MH/MR Program looks to the future of residential
      programs the focus will continue to be on Life Sharing as the first option for our
   2. Becoming an active member of the Life Sharing trainings and subcommittee with
      meetings held bi-monthly.

Dauphin County MR Annual Plan FY 08/09      9
   3. The plan also includes working on a regular basis to continue positive discussions
      at monthly provider meetings held with the agencies that maintain Life Sharing
      services in Dauphin County. These discussions will include possible candidates
      for Life Sharing programs and innovative ways to fund these programs with
      limited increases in expansion funds.
   4. Dauphin County will also look at the opportunities for expansion of Life Sharing
      with any new funds that are allocated to the MR program.
   5. As Life Sharing continues to expand in Dauphin County a number of elements
      become clearer in the successful maintenance and development of these
      programs. The success of Life Sharing in Dauphin County is associated with
      thoughtful planning and mindful attention to the support of the families providing
      Life Sharing. As we plan for the future of Life Sharing we will continue to work
      with Agencies to assess the needs of the provider families and draw support plans
      from this information.
   6. Respite hours and days have always been provided to families and this service
      will continue to be available and adjusted to meet the needs of the families.
   7. Dauphin County has always believed that continued training is a very important
      and vital piece to quality service and support to people. The Riverside Training
      Center will continue to be utilized to the fullest capacity possible to assure that
      provider families are up to date on the general and specific knowledge pertaining
      to those they support. Use of the HCQU (Health Care Quality Unit) will also be
      encouraged as a training support for medical concerns related to individuals being
      supported. Dauphin County believes that the success of every program is
      determined by the support and knowledge you provide to those that work face to
      face with individuals.

Dauphin County MR Annual Plan FY 08/09     10
                        ADDITIONAL Challenges
   1. Demand for service versus service availability
   The biggest problem that we face is that the level of requested need for the services
   provided by the Mental Retardation System continues to exceed the availability of
   services. There continues to be a waiting list for services, and there are always
   individuals who are in emergency or critical need for services. This problem has
   become increasingly severe, not just in Dauphin County, but across the state and
   nation. Emergency needs are regularly brought to the attention of the service system
   when individuals become homeless, are experiencing severe problems, or natural
   support networks fail. Often these individuals come to the attention of the system
   with dual diagnosis (MH-MR issues, behavioral support needs, or multiple medical
   conditions. Historically, the Dauphin County Mental Retardation System has
   developed a network of supports and services that has been able to respond quickly in
   these situations. However, there are resource limits, which at times can be quite
   challenging. Meanwhile, service providers have costs, such as health care insurance,
   that keep rising, and they continue to experience problems in adequately
   compensating the direct service staff in these programs.

   The Family Support Associates Respite House, which was designed to provide relief
   for families, has been turned into an emergency, short-term placement solution on
   many occasions. Residential providers are asked to make accommodations in
   creative ways, with existing funds, for more people. Often when these individuals
   come into care, they are experiencing difficulties and are in need of extra support and
   behavioral expertise.

   2. Providing services and supports to young persons transitioning from the
       educational system upon graduation, typically at age 21:
   These individuals have had the benefit of an entitlement to early intervention services
   and to a free and appropriate public education. After leaving school, they find that
   there is no entitlement to Mental Retardation Services, even though the needs are
   often very significant and devastating to families’ lifestyles if unmet. Most
   individuals with employment potential may have another resource because they are
   eligible for services through the Office of Vocational Rehabilitation for job training
   and placement. However, after OVR's job is done, long- term ―follow along‖ and job
   coaching is an MH/MR responsibility, and we often cannot guarantee it will be
   available. Individuals who need more traditional day programs or individualized
   support have only the MH/MR system as a funding resource, unless they are able to
   private pay.

   3. Waiver requirements to meet all needs to enter the waiver.
   About 85% of the persons whom we serve are Medicaid eligible. However, they
   cannot enter a waiver program until there is funding available in a waiver to meet all
   of their needs. Those who are being served in the waivers must have all of their
   needs met before new recipients can get services. In essence, counties are in the

Dauphin County MR Annual Plan FY 08/09     11
            position of trying to manage a large entitlement for services with insufficient funds.
            We are the gatekeepers, and we are the authority that has to say no to services or ask
            people to wait for services.

            4. System infrastructure and staff retention and recruitment issues.
            Dauphin County contracts with over fifty private agencies and individuals to provide
            Mental Retardation and Early Intervention services. Many of these agencies are
            private, non-profit 501 (c) 3 organizations with roots in the local community. Some
            are large, multi-county MH/MR providers of long standing in the MH/MR system.
            Some are more generic community providers, such as providers of senior citizen day
            care, or providers of information and referral. Still others are individual or small
            practice providers of physical, speech, occupational, and behavior therapy. Many of
            these agencies do fund rising and have developed other forms of community support
            to try to make up for the deficits between the government funding they receive and
            the cost of the needed services that they provide.

            The system has been historically under-funded. The most urgent problem is the need
            for agencies to be able to offer their staff members a competitive annual cost of living
            pay increase and benefits. These staff persons are the key component to our service.
            The field has had difficulty in recruiting and retaining a qualified workforce for many
            years. These ongoing funding challenges have exacerbated an already critical
            problem with direct service staff recruitment and retention. Staff turnover can also
            affect the quality of the service that is provided. A permanent solution needs to be
            developed so that an adequate workforce can be available to meet these vital human
            service needs.

Narrative        Shirley Keith Knox     Deputy MR              717.780-7042
Spreadsheets Joy Hafer                  Wavier Coordinator     717.780-7041

      Dauphin County MR Annual Plan FY 08/09         12

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