    [House Hearing, 109 Congress]
    [From the U.S. Government Publishing Office]

     DISABLED SERVICES IN THE DISTRICT OF COLUMBIA: WHO IS PROTECTING THE
                  RIGHTS OF D.C.'S MOST VULNERABLE RESIDENTS?

    =======================================================================

                                    HEARING

                                   before the

                                  COMMITTEE ON
                               GOVERNMENT REFORM

                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED NINTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 JUNE 16, 2006

                                   __________

                               Serial No. 109-158

                                   __________

           Printed for the use of the Committee on Government Reform

      Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                                   index.html
                          http://www.house.gov/reform

                                     ______

                        U.S. GOVERNMENT PRINTING OFFICE
    28-625                      WASHINGTON : 2006
    _____________________________________________________________________________
    For Sale by the Superintendent of Documents, U.S. Government Printing Office
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                         COMMITTEE ON GOVERNMENT REFORM

                         TOM DAVIS, Virginia, Chairman
    CHRISTOPHER SHAYS, Connecticut       HENRY A. WAXMAN, California
    DAN BURTON, Indiana                  TOM LANTOS, California
    ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
    JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
    JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
    GIL GUTKNECHT, Minnesota             CAROLYN B. MALONEY, New York
    MARK E. SOUDER, Indiana              ELIJAH E. CUMMINGS, Maryland
    STEVEN C. LaTOURETTE, Ohio           DENNIS J. KUCINICH, Ohio
    TODD RUSSELL PLATTS, Pennsylvania    DANNY K. DAVIS, Illinois
    CHRIS CANNON, Utah                   WM. LACY CLAY, Missouri
    JOHN J. DUNCAN, Jr., Tennessee       DIANE E. WATSON, California
    CANDICE S. MILLER, Michigan          STEPHEN F. LYNCH, Massachusetts
    MICHAEL R. TURNER, Ohio              CHRIS VAN HOLLEN, Maryland
    DARRELL E. ISSA, California          LINDA T. SANCHEZ, California
    JON C. PORTER, Nevada                C.A. DUTCH RUPPERSBERGER, Maryland
    KENNY MARCHANT, Texas                BRIAN HIGGINS, New York
    LYNN A. WESTMORELAND, Georgia        ELEANOR HOLMES NORTON, District of
    PATRICK T. McHENRY, North Carolina       Columbia
    CHARLES W. DENT, Pennsylvania                    ------
    VIRGINIA FOXX, North Carolina        BERNARD SANDERS, Vermont
    JEAN SCHMIDT, Ohio                       (Independent)
    ------ ------

                          David Marin, Staff Director
                    Lawrence Halloran, Deputy Staff Director
                           Teresa Austin, Chief Clerk
              Phil Barnett, Minority Chief of Staff/Chief Counsel

                                C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on June 16, 2006....................................     1
    Statement of:
        Bobb, Robert C., Deputy Mayor/city administrator, government
          of the District of Columbia; Brenda Donald Walker, Deputy
          Mayor for Children, Youth, Families, and Elders, government
          of the District of Columbia; Marsha Thompson, former
          administrator, District of Columbia, Mental Retardation and
          Developmental Disabilities Administration; Robert M.
          Gettings, executive director, National Association of State
          Directors of Developmental Disabilities Services; Holly
          Morrison, vice president and chief administrative officer,
          the Council on Quality and Leadership; and Tina M.
          Campanella, executive director, the Quality Trust for
          Individuals With Disabilities..............................    19
            Bobb, Robert C...........................................    19
            Campanella, Tina M.......................................   105
            Gettings, Robert M.......................................    87
            Morrison, Holly..........................................    99
            Thompson, Marsha.........................................    79
            Walker, Brenda Donald....................................    24
    Letters, statements, etc., submitted for the record by:
        Bobb, Robert C., Deputy Mayor/city administrator, government
          of the District of Columbia, prepared statement of.........    21
        Campanella, Tina M., executive director, the Quality Trust
          for Individuals With Disabilities, prepared statement of...   107
        Cummings, Hon. Elijah E., a Representative in Congress from
          the State of Maryland, prepared statement of...............    16
        Davis, Chairman Tom, a Representative in Congress from the
          State of Virginia:
            Prepared statement of....................................     3
            Prepared statement of University Legal Services, Inc.....     6
        Gettings, Robert M., executive director, National Association
          of State Directors of Developmental Disabilities Services,
          prepared statement of......................................    90
        Morrison, Holly, vice president and chief administrative
          officer, the Council on Quality and Leadership, prepared
          statement of...............................................   101
        Thompson, Marsha, former administrator, District of Columbia,
          Mental Retardation and Developmental Disabilities
          Administration, prepared statement of......................    81
        Walker, Brenda Donald, Deputy Mayor for Children, Youth,
          Families, and Elders, government of the District of
          Columbia:
            Information concerning Evans v. Williams.................    26
            Prepared statement of....................................    74
        Watson, Hon. Diane E., a Representative in Congress from the
          State of California, prepared statement of.................   136
        Waxman, Hon. Henry A., a Representative in Congress from the
          State of California, prepared statement of.................   133

     DISABLED SERVICES IN THE DISTRICT OF COLUMBIA: WHO IS PROTECTING THE
                  RIGHTS OF D.C.'S MOST VULNERABLE RESIDENTS?

                                  ----------

                             FRIDAY, JUNE 16, 2006

                              House of Representatives,
                                Committee on Government Reform,
                                                        Washington, DC.
        The committee met, pursuant to notice, at 10 a.m., in room
    2154, Rayburn House Office Building, Hon. Tom Davis (chairman
    of the committee) presiding.
        Present: Representatives Tom Davis, Kucinich, and Norton.
        Staff present: Rob White, communications director; Andrea
    LeBlanc, deputy director of communications; Victoria Proctor,
    senior professional staff member; Shalley Kim, professional
    staff member; Teresa Austin, chief clerk; Sarah D'Orsie, deputy
    clerk; Tony Haywood, minority counsel; and Jean Gosa, minority
    assistant clerk.
        Chairman Tom Davis. The committee will come to order.
        I want to welcome everybody to today's hearing on the
    District of Columbia's Mental Retardation and Developmental
    Disabilities Administration.
        We convene this morning because at a time when so many
    things are going right for the District, a longstanding,
    seemingly intractable problem has painfully reemerged and
    demands our attention.
        The District's fundamental responsibility to be a humane
    and nurturing custodian of those with mental retardation and
    developmental disabilities is not being met. Some say the
    situation is irreparable, and the entire function should be
    taken out of the District's hands and given to a receiver. But
    even if that happens, the District has to find a way to reform
    the current system and meet the needs of these most vulnerable
    citizens.
        How did it come to this? The story is a long and sad one.
    In 1976, after the deaths of two residents at Forest Haven, a
    facility for this population, a Federal class action lawsuit
    was filed against the District. Today captioned as Evans v.
    Williams, the case challenged the conditions of the confinement
    for residents of the institution which was subsequently closed.
    But the judgment against the District also imposes continuing
    obligations, under court supervision, to protect class members
    from harm and to provide services in the least restrictive
    setting for the duration of their lives. Generally, that meant
    the District should be able to provide community-based living
    situations in group homes.
        In 1999, the Washington Post chronicled the tragedy of at
    least 24 deaths of residents in group homes operated in the
    city agency, the MRDDA. The articles highlighted chronic abuse
    and neglect of developmentally disabled individuals and
    described profiteering by some vendors operating group homes.
    Six years later a day program worker was charged with criminal
    negligence for burning an adult home resident. In March 2006,
    an employee of a day program for disabled persons pled guilty
    to charges of sexually abusing a patient. MRDDA made headlines
    again when the court monitor reported in February 2006 that a
    woman and three men had died since November 2004 because of
    inadequate health care. The report attributes the deaths to a
    systemic pattern of negligence in the homes and lack of
    oversight. The court monitor said that, ``for a period of over
    1 year the District repeatedly failed to notify providers of
    the results of mortality investigations conducted by its own
    reviewer. As a result, corrective actions were never discussed,
    let alone implemented or evaluated.''
        Some attribute this lack of accountability to scattered
    lines of authority in the city government. In effect, MRDDA has
    the responsibility, but not the authority over key functions
    required to provide quality care and protect vulnerable lives.
    Enforcement, personnel, facility licensing and contracting
    powers are scattered across disparate city agencies. In that
    structure MRDDA can achieve some reform, but not nearly enough
    to meet the court mandate or meet the needs of current and
    future residents. The inability of agencies with varying levels
    of responsibility for this population to communicate
    effectively has added to the failure to act timely and
    decisively.
        The bottom line is there needs to be a single point of
    authority and accountability, and there must be performance and
    outcome measures to gauge the city's progress.
        The committee has conducted oversight of several D.C.
    agencies and departments which have been the subject of lengthy
    lawsuits, many of which resulted in court appointed
    receiverships, including the child welfare system, mental
    health services and the housing authority. Five district
    agencies were placed in receivership in 1999 when Mayor
    Williams came into office. He made the commitment to regain
    control of the agencies and has successfully done so. It's past
    time to bring the same commitment and sense of urgency to
    fixing the MRDDA.
        Thirty years of court orders, monitors and compliance plans
    have not worked to fix a broken approach to this special
    population. Today, we need to hear how the District plans to
    end this agonizing era of neglect, reform program management,
    establish visible and meaningful quality controls, and assume
    full responsibility for those who need and deserve the city's
    compassion and care.
        I like to include in the record a statement by University
    Legal Services; and without objection, so ordered.
        I would now recognize another champion of the disabled in
    this particular city, Ms. Norton.
        [The prepared statement of Chairman Tom Davis follows:]

        [GRAPHIC] [TIFF OMITTED] T8625.001

        [GRAPHIC] [TIFF OMITTED] T8625.002

        [The prepared statement of University Legal Services, Inc.
    follows:]

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    [GRAPHIC] [TIFF OMITTED] T8625.010

        Ms. Norton. Thank you very much, Mr. Chairman.
        Mr. Chairman, I really regret that the committee has found
    it necessary to hold this hearing on services provided by a
    local D.C. agency. And we all know that this Chair does not do
    so often, and he doesn't do it lightly, because he is a strong
    supporter of home rule. And this is, frankly, a classic home
    rule matter that doesn't belong in the U.S. Congress. As a
    matter of fact, Mr. Chairman, I have a letter coming to you
    concerning hearings I wanted the U.S. Attorney, who is
    unfortunately a Federal official--and on structural deficit,
    where you promised me a hearing. But I can understand why this
    caught the attention of the chairman. Congress has learned that
    when--the city has learned that when matters that are quite
    inflammatory come to the attention of the Congress through the
    newspapers it gets congressional attention.
        The recent request for a receivership, provided by the
    Mental Retardation and Development Agency brings this matter
    too close to the congressional orbit for comfort because the
    Federal courts would be involved or if the D.C. courts were
    involved, those come under the jurisdiction of the Congress at
    this point.
        So the death in group homes, the abuse of helpless people
    making the papers--anybody in this city knows that Congress
    reads the papers, too. And of course one doesn't have to be
    personally affected to understand why mentally--retarded, and
    developmentally disabled residents would catch the attention of
    this body. These are our citizens that are often at the mercy
    of whoever is in charge, and has the responsibility for their
    well-being. Well, who has the responsibility is not the
    Congress of the United States, it is the society defined as the
    citizens of the District of Columbia, and of course the MRDDA.
    So the concern could not be more well placed.
        I raise the issue of whether a Congressional hearing is
    necessary or appropriate, not because of the seriousness of the
    issue--nothing could be more serious than the issues involving
    people who can't take care of themselves when no one else seems
    to be taking care of them. I do note that the hearing is being
    held at a time when in the papers there is evidence both of
    some council leadership indicating that there is oversight in
    the city which knows the issue best, and of course where there
    have been some changes made; tardy though they were--for
    example, an experienced and new director on board. The council
    certainly takes the matter seriously. They take it so seriously
    that they have invoked the harshest punishment; denying the
    agency increases pending improvement. You couldn't get people's
    attention better than that. And of course it has a terrible
    downside that I hope all involved will understand so that we
    can quickly get the matter back to some sense of normalcy.
        It is an extremely complicated matter. Many agencies
    providing the necessary services, or even finding group homes
    in a city like this where people are being chased out every day
    by the cost of housing, as the market has escalated those
    costs. Nobody wants a group home, even for these residents who
    are helpless. The problem the city has found in getting
    contractors, people who supervise these citizens is itself a--
    who are competent to do so--is a story all its own. And of
    course the difficulty is magnified by the fact that these
    citizens are not located in one place. They are spread across
    the city, as well they should be because we're trying to
    provide a normal environment for them in the least restrictive
    setting.
        So I stress that the only way to get systematic oversight
    is for the city to increase oversight, and the alternative to
    that is not congressional oversight. The alternative to that is
    something that the city wants least, and that is third party
    oversight, like a receiver. And what a shame that would be, to
    head back to 5 or 6 years ago when so many agencies were in
    receivership. This happens all across the country in other
    cities as well. But here was the District, after the control
    board period--which literally brought troubled agencies out of
    receivership, every last one of them. And as a result, there
    hasn't been much said here in Congress because the fact that
    they were in receivership brought them right under our nose and
    jurisdiction.
        It was a great achievement, but in a real sense--it was a
    great achievement because it shows that the government was
    working, because the courts would not have released these
    agencies' receivership if the courts didn't think that the city
    could do it. But if the agencies that have responsibility for
    these citizens aren't working, the conclusion will be the
    government isn't working. This is a real test of whether the
    government works. I know we don't want to head back to 30 years
    ago, and I really don't believe that's where we're headed.
    Those of us who group up in this city remember Evans v.
    Williams, the class action that started it all, went on for so
    many years, the closing of the old Forest Haven, the move to
    group homes for the least restrictive environment.
        Given recent responses, what we're trying to find out is
    whether the city gets the point and is on a systemic road, the
    kind of systemic road it will take to straighten this out
    before we go all the way back to control board times when in
    essence we had a control board for these agencies.
        This hearing is yet another outside intervenor that should
    get the city's attention. The city finds congressional
    intervenors particularly undesirable, but worse, much worse
    would be a receivership. I can't believe, I don't believe that
    this administration intends to come full circle and head back
    to the bad old days, but I can't know for sure. That's why I
    will be listening very attentively to the witnesses today. I
    welcome them and appreciate their testimony.
        Chairman Tom Davis. Thank you, Ms. Norton.
        I can just say that we didn't rush into this hearing willy-
    nilly . I mean, we've been waiting a long, long time for some
    action. It just gets worse. And I think I would be not
    fulfilling my responsibility as chairman to move forward and
    shed some light on this, as we have always worked together to
    try to give the city the resources it needs and understand the
    particulars of home rule. But I think this situation has
    dragged on and on and on, and that's the reason for the hearing
    today.
        Members will have 7 days to submit opening statements for
    the record.
        [The prepared statement of Hon. Elijah E. Cummings
    follows:]

    [GRAPHIC] [TIFF OMITTED] T8625.011

    [GRAPHIC] [TIFF OMITTED] T8625.012

        Chairman Tom Davis. We're going to recognize our
    distinguished panel. Mr. Robert C. Bobb, the Deputy Mayor/city
    administrator; Ms. Brenda Donald Walker, the Deputy Mayor for
    Children, Youth, Families and Elders, Government of the
    District of Columbia; Ms. Marsha Thompson, former administrator
    for the District of Columbia Mental Retardation and
    Developmental Disabilities Administration; Mr. Robert Gettings,
    executive director of the National Association of State
    Directors of Developmental Disabilities; and Ms. Holly
    Morrison, vice president and chief administrative officer of
    the Council on Quality and Leadership; and Tina Campanella, the
    executive director of the Quality Trust for Individuals with
    Disabilities.
        We may have a vote on the floor between 11 and 11:30. If
    we're not through, it would be my intent at that point to just
    hand the gavel over to Ms. Norton, if she has questions, to
    allow that to happen while I go vote. I regret that she can't
    come over and vote on this resolution and cancel my vote out,
    but we're working on that. But just to kind of keep things
    going and try to--if we have questions.
        It's our policy that all our witnesses be sworn before they
    testify, so if we can have the witnesses come forward. And let
    me thank you all for coming today. If you could raise your
    right hands. Thank you.
        [Witnesses sworn.]
        Chairman Tom Davis. Thank you very much.
        Mr. Bobb, you're no stranger to the committee, and I'll
    start with you. We have a light in front of you--your entire
    statements are in the record. The light will turn green when
    you start, orange after 4 minutes, red after 5. Since your
    entire statement is in the record and we have some questions
    we're prepared to ask off that, you don't need to go forward
    unless you feel you have to. And we, of course, don't--if you
    feel you have to say, we won't cut you short, but it makes it
    go crisper if we can stay within it.
        Mr. Bobb, thanks for being with us. And as I said before,
    this city is doing a lot of things right. And this is just one
    area that we've not been able to get our hands around and
    solve, and that's the purpose for the hearing today. But I
    don't want to be overly critical on so many other things that
    are going right in this city, and we appreciate you and the
    mayor's leadership.

    STATEMENTS OF ROBERT C. BOBB, DEPUTY MAYOR/CITY ADMINISTRATOR,
     GOVERNMENT OF THE DISTRICT OF COLUMBIA; BRENDA DONALD WALKER,
        DEPUTY MAYOR FOR CHILDREN, YOUTH, FAMILIES, AND ELDERS,
    GOVERNMENT OF THE DISTRICT OF COLUMBIA; MARSHA THOMPSON, FORMER
      ADMINISTRATOR, DISTRICT OF COLUMBIA, MENTAL RETARDATION AND
    DEVELOPMENTAL DISABILITIES ADMINISTRATION; ROBERT M. GETTINGS,
    EXECUTIVE DIRECTOR, NATIONAL ASSOCIATION OF STATE DIRECTORS OF
       DEVELOPMENTAL DISABILITIES SERVICES; HOLLY MORRISON, VICE
      PRESIDENT AND CHIEF ADMINISTRATIVE OFFICER, THE COUNCIL ON
       QUALITY AND LEADERSHIP; AND TINA M. CAMPANELLA, EXECUTIVE
     DIRECTOR, THE QUALITY TRUST FOR INDIVIDUALS WITH DISABILITIES

                      STATEMENT OF ROBERT C. BOBB

        Mr. Bobb. Thank you very much. And good morning, Chairman
    Davis and Ms. Norton, members of the Committee on Government
    Reform.
        I'm Robert C. Bobb, city administrator/Deputy Mayor for the
    District of Columbia, and I'm here today on behalf of Mayor
    Anthony Williams.
        It is my pleasure to address the committee concerning the
    work that has been and is being done in the District to improve
    the Mental Retardation and Developmental Disabilities
    Administration. Mayor Williams and I remain committed to making
    the necessary changes to improve this agency.
        MRDDA is facing tremendous and diverse challenges. As you
    are well aware, MRDDA has struggled for years to improve its
    service delivery and to attract and maintain competent
    providers.
        In addition to addressing service delivery concerns, the
    Williams administration is working to ensure that the day-to-
    day management of the agency is strengthened. For the past
    several months I have been a regular participant at the weekly
    meetings with Deputy Mayor Brenda Donald Walker and MRDDA
    senior management. During our budget review process, we have
    been working with the District Council to make certain that the
    agency is appropriately funded.
        In selecting the new MRDDA Administrator Cathy Sawyer, the
    Mayor and I sought a strong director with a proven track record
    of turning a troubled agency around. A lot can be accomplished
    in the next 6\1/2\ months, and we are convinced that Ms. Sawyer
    is the right person to be at the helm. During her tenure, we
    will also conduct a search to identify candidates for the
    permanent director.
        In summary, we truly believe that we are laying the right
    foundation for MRDDA so that it will provide the necessary
    services and care that we all want for District residents
    facing mental and developmental challenges.
        Let me also state unequivocally that we are opposed to the
    appointment of a receivership. The Williams administration
    continues to seek the necessary changes to make MRDDA a better
    functioning operation. Yes, the task has taken longer than we
    anticipated; however, with the concerted attention the agency
    is under, internally and externally, and with the addition of a
    nationally recognized expert in these matters, we are convinced
    that improvements will be made before the end of the year.
        Thank you.
        [The prepared statement of Mr. Bobb follows:]

        [GRAPHIC] [TIFF OMITTED] T8625.013

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        [GRAPHIC] [TIFF OMITTED] T8625.015

        Chairman Tom Davis. Thank you very much.
        Ms. Walker.

                   STATEMENT OF BRENDA DONALD WALKER

        Ms. Walker. Good morning, Chairman Davis and Congresswoman
    Norton. My name is Brenda Donald Walker, and I am Deputy Mayor
    for Children, Youth, Families and Elders for the District of
    Columbia.
        Prior to being appointed Deputy Mayor in November 2005, I
    was the director of the Child and Family Services Agency for
    the District. I was recruited to CFSA as a chief of staff to
    help guide that agency through major reforms and transition out
    of court imposed receivership. By virtue of a tremendous amount
    of work, fiscal responsibility, innovative practices and a
    solid management team, we were able to create what is now a
    well regarded child welfare agency.
        I offer this history because the challenges facing MRDDA
    today resemble very much the issues facing CFSA when I started
    there 5 years ago.
        As you know, MRDDA faces formidable challenges, including
    budget, management and service delivery. We have had literally
    decades of decay at MRDDA, yet I come before you today to
    testify that I believe we are on the right track.
        As with our accomplishments at CFSA, MRDDA cannot be
    transformed in months, but rather over several years. However,
    the critical foundation--that upon which substantial reform
    will be built, can be laid in the next 6 months.
        As the city administrator just mentioned, the Mayor
    recently appointed Cathy Sawyer as the new administrator for
    MRDDA. Ms. Sawyer has consulted for the agency since last
    October, thus developing a working knowledge of the agency, so
    she will hit the ground sprinting when she starts on Monday.
        In accepting the position, Ms. Sawyer has identified three
    primary goals for the next 6 months; one, positioning MRDDA to
    effectively operate within its budget; two, successfully
    amending the existing home and community based waiver; and
    three, establishing a solid organizational foundation to enable
    MRDDA to function more efficiently and effectively in its
    delivery of services.
        The coming months will be intense and critical. Everyone
    who has met Cathy Sawyer comes away impressed with her
    confidence, experience and commitment to improving the lives of
    persons with disabilities. I would like to have her brief you
    and your staff in the next few months after she has had a
    little bit of time to begin work on executing her goals.
        Ms. Sawyer represents only one component of our recent
    efforts. As I mentioned, a strong management team is essential.
    We have also added a Chief Operating Officer, Dr. Heather Stow,
    who is here with me today. Dr. Stow has over 20 years of senior
    management experience in the human services field. We've also
    recently hired a highly regarded quality assurances manager, a
    new director of programs, and several other senior staff.
        Over the last several months we conducted an organizational
    and staffing analysis of MRDDA. And the city administrator and
    I will support Ms. Sawyer's rapid implementation of the
    critical management and organizational changes needed to move
    the agency forward.
        Much of our work at MRDDA since I became Deputy Mayor, and
    more intensely in the last 4 months, has been driven by the
    systems improvement plan that I outlined to address the
    agency's basic structural deficiencies. This plan has seven
    major components: one, expansion of provider capacity; two,
    provider monitoring and accountability; three, contracts
    management; four, feasibility of waiver operations; five,
    improvement in day programs; six, case management; and seven,
    training. Through intensive weekly meetings which I chair, we
    are closely tracking our progress, modifying things when
    necessary and, most importantly, remaining focused.
        As you are aware, we also face a significant legal
    challenge to our stewardship of MRDDA. Counsel for the
    plaintiffs' class in the U.S. Department of Justice filed
    motions for receivership and contempt in the longstanding class
    action lawsuit, Evans v. Williams. I am making available for
    the committee's records copies of the District's oppositions to
    those motions, as well as my declaration submitted to the court
    on Monday.
        [The information referred to follows:]

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        Ms. Walker. Our work over the next few months--over the
    last few months and in the 6 months ahead is designed to lay
    the foundation for long-term systemic reform. With the
    commitment of the Mayor, the support of the city administrator
    and MRDDA's new leadership, we are confident that we can
    finally get this agency on track.
        Thank you for the opportunity to update you on our plans
    for MRDDA, and I'm available for your questions.
        [The prepared statement of Ms. Walker follows:]

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        Chairman Tom Davis. Thank you very much.
        Ms. Thompson.

                      STATEMENT OF MARSHA THOMPSON

        Ms. Thompson. Hello, Chairman Davis and Congresswoman
    Norton. I'm Marsha H. Thompson, former administrator of the
    District of Columbia's Mental Retardation and Developmental
    Disabilities Administration.
        I believe that while Mayor Williams may have already made
    changes in structure and policy to support the incoming
    administrator, my sincerest hope is that my comments can
    contribute to improving the outcomes for this population, which
    I tried my very best to serve as administrator.
        I began as interim administrator in May 2005, just in time
    for the mid-year budget review with D.C. Department of Human
    Services. DCDHS is the cabinet level agency above MRDDA.
        Former Deputy Mayor Neil Albert and I determined that
    amending our MRDDA Medicaid waiver to reduce the burden on the
    local budget was a critically needed step. I hired a waiver
    specialist, formed a waiver work group, communicated budget
    pressures and possible solutions to the provider, advocacy and
    client community, and began work on the needed waiver
    revisions.
        The parties associated with the Evans court decree insisted
    that MRDDA quickly move people from homes fully funded by the
    D.C. Medicaid budget, implement a restructure, and provide
    improved specialized health care services through private
    health care practitioners and hospitals. I communicated the
    increasing spending pressures to Mr. Albert. He called an all-
    hands meeting to develop a plan for funding to continue
    services during that year, and after which he determined what
    should be done to meet the needs in fiscal year 2006. He
    advised that I complete the amendment for the current MRDDA
    waiver, prepare a supplemental budget request to the Mayor for
    fiscal year 2006, and collaborate with an expert to better
    leverage local funds for the capture of the Federal match in
    other ways.
        Even though former Deputy Mayor Neil Albert and I had
    previously mapped out a structure for MRDDA, I was unable to
    implement it due to funding challenges and the hybrid legal
    status under which we were operating. As of June 6, 2006, MRDDA
    was in need of internal legal counsel to handle the daily court
    appearances around client services and many other legal
    obligations, internal budget staff with adequate fiscal acumen
    who could directly access fiscal reports and forecasts,
    internal contract staff with the authority to negotiate
    contracts and monitor performance, an internal human resources
    office to manage personnel functions. MRDDA did have an
    assigned personnel specialist, but the office was not
    adequately functioning as of June 6, 2006. Internal information
    technology staff with the requisite skills to manage complex
    information management needs and design improvements for
    responsive and comprehensive information.
        MRDDA is one of many city agencies that must work closely
    together to achieve the outcomes required by the Evans plan.
    These agencies include D.C. Medicaid, D.C. Office of
    Contracting, etc. The coordination and responsiveness of these
    agencies in support of people with disabilities has always been
    recognized as critical to meeting the compliance measures in
    Evans. The Mayor has delegated responsibility for coordination
    to the Deputy Mayor for Children, Youth, Families and Elders.
        The District MRDDA is in need of radical realignment. The
    replacement of the administrator is, quite frankly, a woefully
    inadequate step in alleviating the systemic problems of this
    administration. I submit a few items to be considered and given
    support to be implemented: MRDDA needs the undivided attention
    of executive leadership and should therefore report directly to
    the city administrator. Mr. Bobb is a well known and well
    respected administrator.
        Consistent budget overruns from a social services program
    of this magnitude and with these persistent issues cries out
    for adequate funding and appropriate performance measures.
        A new Medicaid waiver and the resources to carry out the
    program's mandate must be implemented now.
        Executive leadership coupled with a legislative committee
    chair who will commit the time to understanding the community.
        And without the above minimal commitments, the agency
    should be immediately placed into receivership.
        While the District is moving in a positive direction and
    I'm sure will continue to buildupon its accomplishments to
    date, much is left to be done at all levels of government. My
    primary regret is that I was unable to garner the appropriate
    level of support to bring systems change to MRDDA.
        Thank you.
        [The prepared statement of Ms. Thompson follows:]

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        Chairman Tom Davis. Thank you very much.
        Mr. Gettings.

                    STATEMENT OF ROBERT M. GETTINGS

        Mr. Gettings. Thank you, Mr. Chairman.
        Mr. Chairman, my name is Bob Gettings, and I am the
    executive director of the National Association of State
    Directors of Developmental Disabilities Services, an
    organization that represents public developmental disabilities
    agencies in the 50 States and the District of Columbia.
        I come before you today to discuss my observations
    concerning the prerequisites of an effectively managed service
    delivery system for persons with developmental disabilities. In
    drawing together these observations, I draw upon 40 years of
    experience in working with State and local disability officials
    to improve services to this population.
        You have already heard from the previous witnesses some of
    the issues that are faced. I just want to bring it back to this
    level. Two of the foundational rules of public administration
    are that authority must be commensurate with responsibility and
    public servants must be held accountable for their performance.
    I'm pleased to hear from Mr. Bobb and Ms. Walker that the
    District is committed to changing some of the issues, but the
    truth is that is not the way in which--and these rules have not
    been followed in the past.
        The Mental Retardation and Developmental Disabilities
    Administration is responsible under the city code for
    delivering high quality services to eligible individuals, but
    because the city is highly reliant, as all 50 States are
    reliant, on Medicaid as a funding source, the funding of
    services are divided between MRDDA and the Medical Assistance
    Administration, which is the single State Medicaid agency in
    the District. As a consequence, funding an administrative
    authority for the city's services are not carried out in a
    unified manner.
        I think that--and I want to stress that Federal Medicaid
    regulations allow States, to administer programs in a unified
    way. In the District of Columbia prompt steps need to be taken
    to develop an effective interagency agreement between the
    Medical Assistance Administration and MRDDA, governing the
    management of Medicaid dollars that support specialized long-
    term services for persons with developmental disabilities.
        A central aim of this agreement should be to assign clear,
    unambiguous authority to MRDDA to manage services in a unified
    manner. That means pulling together all specialized services,
    whether they're derived from Medicaid or non-Medicaid sources.
    I think you said it well in your opening statement, Mr.
    Chairman, there needs to be a single point of responsibility
    and accountability within city government for assuring that
    services in this population work.
        Unlike most jurisdictions, the District continues to rely
    heavily on the ICFMR service model as its primary method of
    drawing down Medicaid assistance. Over 60 percent of the budget
    for services in fiscal year 1994 went to payments for ICFMR
    services, and only 3 percent went to the home and community-
    based waiver program.
        You've heard from the previous witnesses a commitment to
    make the home and community-based service system work. The home
    and community-based waiver program has been in existence since
    1998, and I think we're still waiting for those kinds of
    changes.
        At the moment, the District operates one of the smallest
    MRDDA waiver programs in the Nation. Expanding and improving
    the District's waiver program would not only open a variety of
    new financing options, but also allow city officials to claim
    Federal financial participation in the cost of existing
    services to Title XIX eligible persons that are currently being
    funded fully through city revenues. This potentially could add
    $30 to $35 million in additional Federal payments that could be
    deployed to improve some of the weaknesses in the existing city
    infrastructure.
        The District really needs to move aggressively to improve
    the home and community-based waiver program, but I just would
    stress with you that unless existing lines of responsibility
    and accountability are clarified and a single District official
    is charged with assuring that this task is successfully and
    expeditiously completed, recent history strongly suggests that
    the waiver renewal process will remain mired in a sea of
    bureaucratic infighting.
        I want to stress as well that in the 2001 compliance plan
    MRDDA is responsible for developing a comprehensive quality
    management program, yet at the current time the responsibility
    for monitoring and complying with city rules currently rests
    with the Health Regulation Administration within the Department
    of Health. Because of this division of responsibility and
    because of the lack of effective interagency coordination,
    provider agencies often receive mixed signals about where their
    emphasis should lie. There is an urgent need for the District
    government to develop a global plan for monitoring and
    improving the quality of services.
        Within the next 10 months, the city will be responsible for
    submitting waiver renewal requests to the Centers for Medicare
    and Medicaid Services. That request will have to include a
    comprehensive quality management plan, which is now a new
    requirement of CMS. That's going to take a lot of work. That's
    an area that needs to be given attention.
        Faced with the catastrophic consequences of the city's past
    failure to protect its most vulnerable citizens from harm,
    there is, I think, an understandable tendency on everybody's
    part to grasp for quick solutions. Certainly anyone familiar
    with the current problems facing the District's DD service
    system has to acknowledge the need for prompt, corrective
    actions, and a sense of urgency in implementing them. Immediate
    steps to stabilize the situation, however, need to be linked to
    a broader set of systemic change strategies aimed at improving
    the District government's capacity to effectively manage
    services for individuals with disabilities over the long haul.
        One of the central lessons that can be drawn from the sad
    history of the Evans litigation, and indeed from similar class
    action lawsuits across the country, is that deep-seated
    systemic failures won't be resolved by a series of quick
    overnight fixes. The service
    system needs to be rebuilt from the bottom up, and that
    requires commitment and sustained leadership from government
    officials at all levels, especially top elected and appointed
    officials.
        Thank you, Mr. Chairman.
        [The prepared statement of Mr. Gettings follows:]

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        Chairman Tom Davis. Thank you very much.
        Ms. Morrison, thanks for being with us.

                      STATEMENT OF HOLLY MORRISON

        Ms. Morrison. Good morning, Chairman Davis and
    Congresswoman Norton. My name is Holly Morrison, and I'm with
    the Council on Quality and Leadership. I'm currently the vice
    president and chief administrative officer. It's a pleasure to
    be here this morning.
        I think CQL's experience and history make us uniquely
    qualified to discuss performance, measurement and quality
    improvement for services for people with disabilities. National
    organizations founded CQL as a standard setting body in the
    field of intellectual disabilities in 1969. CQL has revised and
    published successive editions of its standards on a continuous
    basis in 1971, 1973, 1978, 1984, 1989, 1991, 1993, 1997, 2000,
    and again in 2005.
        CQL remains a private, nonprofit organization incorporated
    in the District of Columbia and sponsored by the leading
    national organizations in the field of intellectual
    disabilities, including the American Association on Mental
    Retardation, ANCOR, which is the American Network of Community
    Options and Resources, the Arc, the Autism Society of America,
    Easter Seals, Mosaic, National Association of Qualified Mental
    Retardation Professionals, SABE, Self Advocates Becoming
    Empowered, the United Cerebral Palsy Associations, Inc.
        Today, I want to focus attention on accountability rather
    than specific minimum standards, organizational processes or
    accreditation programs.
        CQL and other leading national organizations in the field
    of intellectual disabilities define quality in terms of
    responsiveness to the individual in addition to compliance with
    regulations and organizational processes.
        Compliance with standards and mandated processes provide
    uniform and routine performance requirements, but compliance
    with standards may not result in personal outcome attainment or
    performance improvement. Organizations must measure personal
    outcome attainment, and then constantly adjust standards and
    organizational processes to optimize outcomes.
        Organizational accountability and quality performance
    requires outcome-based assessment. Basic assurances in the
    areas of health, safety, human security and legal rights
    require well-defined performance expectations for staff.
    Quality performance is linked to facilitating the outcomes that
    are important to the individual, to their family, to their
    friends, and the community that supports them.
        Organizations staff professionals and families realize that
    each person is a unique sample of one, that each person has
    unique expectations for such important outcomes as best health,
    safety, respect, friendship and employment.
        The distinction between outcome measurement and compliance
    with process is particularly important for service systems
    operating under close public scrutiny, government reform
    initiatives, and court oversight.
        Standards and organizational processes, policy and
    procedure must facilitate outcomes. Public accountability,
    quality improvement and fiscal responsibility require the
    measurement of outcomes, not just compliance with minimum
    standards.
        Finally, clear definition of outcomes provides the
    necessary platform for staff training and board of director
    education for all service providers. Board of director
    orientation and staff training are necessary components for
    organizational accountability and performance improvement.
        Thank you very much.
        [The prepared statement of Ms. Morrison follows:]

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        Chairman Tom Davis. Thank you very much.
        Ms. Campanella.

                    STATEMENT OF TINA M. CAMPANELLA

        Ms. Campanella. Good morning, Chairman Davis.
        My name is Tina Campanella, and I am the executive director
    of Quality Trust for Individuals with Disabilities, an
    independent nonprofit advocacy organization for people with
    developmental disabilities in the District of Columbia. Thank
    you for this opportunity to testify.
        Our organization is a product of the 2001 settlement
    agreement in the Evans v. Williams class action lawsuit and was
    created to represent all citizens with developmental
    disabilities in D.C., not only the 665 Evans class members.
        The situation for people with developmental disabilities in
    D.C. is very troubling. The current structure and framework for
    services is not working well at all. The critical question is
    how to make fundamental changes in the organization and
    operation of the service system. Quality trust issues are
    advocacy experience to inform our recommendations for change. I
    have included with my testimony a 4-page working document that
    describes the broad changes we feel are needed within the D.C.
    service system to make services responsive to the needs of the
    people it supports.
        While we recognize and commend the efforts of the D.C. City
    Council Humans Services Committee Chair Adrian Fenty and Deputy
    Mayor Brenda Donald Walker, it is important to underscore that
    the D.C. service system cannot be improved without bold and
    dramatic action. The difficulties extend well beyond the
    individual appointed as administrator. The fragmented structure
    of the administration, funding and enforcement functions is at
    the root of problems with performance and accountability.
        Our recommendations target essential elements of a
    functional system. These recommended actions will not fix the
    situation quickly, but they will advance the dialog about how
    to bring greater accountability to the administration, funding
    and oversight of services and supports to people. Some of these
    issues have already been mentioned so I won't go into detail
    here.
        Obviously we need a comprehensive plan to manage the
    dollars that will be coming into the city to fund services to
    the Medicaid program, and that needs to cross over agency
    lines. The waiver application has also been made as a
    recommendation and a priority for many people, and we agree
    that must be made a primary priority.
        Additionally, a coordinated strategy to ensure that
    providers enter the system with prerequisite qualifications,
    and that performance over time is tracked to identify areas
    where difficulties are encountered as needed.
        The functions for licensing, certification and quality
    monitoring now spread over MRDDA and the Department of Health
    Regulatory Agency need to be linked and closely coordinated,
    and again, as you have heard, preferably with one agency taking
    the lead.
        Case management again is a serious issue. We believe it
    needs to be grounded in the tradition of individual advocacy
    and support for people's right to create lifestyles of their
    own choosing to the greatest extent possible.
        An additional issue is that D.C. law provides that all
    individuals who are receiving residential services are entitled
    to an advocate. The structure in process in D.C. to meet this
    requirement is part of the D.C. Supreme Court Family Division.
    This function has not been implemented as envisioned, and it
    has no dedicated funding. Funding for this function has been
    included in the current budget request, and we believe must be
    funded.
        And finally, funds and efforts should be devoted to
    developing a strategy for working together with families and
    providing support to people in their family home. In-home
    family supports provide an important alternative to group
    living arrangements and need to be part of D.C.'s long-term
    strategy for services and supports. The framework for funding
    exists, but will remain unused without specific efforts to
    develop the provider capacity needed to develop this support.
        We are encouraged that D.C. has secured assistance from Ms.
    Cathy Sawyer. We are mindful, however, that these problems that
    she faces are substantial and cannot be fixed overnight through
    policy development and planning.
        The solution requires everyone to remain clearly focused on
    the immediate planning and intervention needed to provide
    adequate and reliable supports for people today, while at the
    same time designing and implementing the structure and capacity
    needed for the future.
        Further, we see great urgency to move forward quickly to
    ensure people with developmental disabilities are protected
    from any additional harm as they are supported to live full and
    productive lives.
        Thank you again for the opportunity to testify, and I will
    be happy to answer any questions.
        [The prepared statement of Ms. Campanella follows:]

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        Chairman Tom Davis. Thank you all very, very much.
        I've got a few questions. I'm going to start, I think, Mr.
    Bobb, with you and Ms. Walker.
        Does the city have any plans to regulate case management?
        Ms. Walker. We do have a case management work group as part
    of the systems improvement plan, and they're looking at all
    aspects of case management, including some different models.
    And the subject of regulation has not come up in my
    conversations specifically, but we'll make sure that's on the
    table.
        Chairman Tom Davis. Yeah. I'll tell you why I say that.
    There is a report that's scheduled to be released on June 22nd,
    and the court monitor states there is a lack of standards
    relating to the case management in MRDDA and that the
    individual support plans fell short of implementation. And that
    may be where you start on this.
        Ms. Walker. I was a little confused by your word
    ``regulate,'' but certainly the adoption of standards and case
    management, monitoring and a whole system is definitely needed
    and is part of the short-term plan.
        Chairman Tom Davis. Now on August 4, 2005, Deputy Mayor
    Albert notified the court of plans to reorganize MRDDA, and to
    do so the parties agreed to the 90-day initiative which was
    designed to demonstrate the District's ability to increase
    meaningful systematic reorganization.
        Does the District still plan to reorganize MRDDA, and can
    you give us a sketch of what you're looking at?
        Mr. Bobb. Yes. MRDDA, this department was part of the
    larger Department of Human Services, and so what we want to do
    is, make it a single agency itself and give it the independence
    that it needs as a single agency. So part of our work this
    coming Monday is to look at, although we've separated it from
    the Department of Human Services, our work is to take it even
    further in terms of how we restructure it as a single agency
    with a lot more independent authority than it currently has,
    and also to ensure some of the issues that have been raised
    with respect to interagency collaboration that's really needed
    at the end of the day to make this agency function even better.
        Chairman Tom Davis. The city put a lot of effort into
    regaining control of the agencies that were in court ordered
    receivership, a lot of effort. And of course we worked with the
    city on that. Mayor Williams even hired a separate counsel to
    spearhead the effort. But back in 2003 the judge in the Evans
    case found it necessary to order the city to appoint a Deputy
    Mayor or other senior official to coordinate the agencies
    responsible for various aspects of compliance with the court
    order.
        Does the Mayor plan to appoint a special counsel or other
    senior official to reform services for the developmentally
    disabled?
        Mr. Bobb. Yes, one of the discussions--I've been involved
    in the Jerry Young case, for instance. So in my office I have
    kind of an internal receiver that works with me and I work
    directly with the plaintiffs in that case; and we're looking at
    a similar model with respect to this agency itself.
        Chairman Tom Davis. Do you have any plans to alter the
    relationship between MRDDA and the Medical Assistance Agency,
    which is the State Medicaid agency?
        Ms. Walker. We certainly are looking at that and have that
    as a major agenda item, because that is mentioned time and time
    again, as it has been today, that it's important to have some
    more coordination if not colonization. I do want to caution the
    committee, as I do our team, that at this point MRDDA really
    needs to focus on its core mission, and that is delivering high
    quality services to the consumers that the agency serves. And
    certainly we know the importance of the interagency
    coordination, and I have found all of our agencies, including
    MAA, to be very responsive. And with the Mayor's directive and
    the city administrator's support, that we--supporting MRDDA is
    a top priority where we are certainly going to be doing that
    over the next few months while we look at the best
    organizational structure. We just have a lot to do over the
    next few months.
        And I want to add, my former agency, CFSA, did have some
    independent authority in certain areas that has been suggested
    that might be beneficial for MRDDA, but I also know that it
    took 3 to 4 years to build that infrastructure, which takes
    away from the core services. And so my direction is that we
    have to focus on the basics first, while at the same time we're
    looking at all of the structural impediments or opportunities
    to make MRDDA better.
        Chairman Tom Davis. Could you elaborate on the systems
    improvements plan, Ms. Walker? What is the objective of the
    plan? And then I'm going to ask anybody else on the panel to
    comment on that, if they have a comment on it.
        Ms. Walker. My assessment of the agency is that some of the
    basic systems have just not been in place. I think that there
    has been a lot of improvement over the last few years in a lot
    of different areas, but you don't have the basic infrastructure
    laid to just operate smoothly. And so we're focusing again on a
    number of areas, but the provider monitoring and accountability
    is a critical area and one that we get criticized, and I think
    rightfully so, by the court monitors and others because we
    don't have a centralized system for really evaluating and being
    able to respond quickly to problems with our providers or when
    consumers have problems with services. We need a centralized
    system, and we have that, we developed that for CFSA, and I'd
    like to look at a similar model. But basically it's where all
    of the information comes together so that you're making
    informed decisions about who is a good provider, who is not, is
    case management business being done on time, and while that
    information comes together, right now it is very chaotic.
        So provider accountability is one key area. Contracts
    management is another area that goes to our ability to access
    better services, including the waiver services.
        The feasibility of waiver operations, we're looking at day
    programs and the whole case management model, as well as basic
    training. So we have that, and we have details. If you'd like
    us to forward the plan to the staff, we'd be happy to do that.
        Chairman Tom Davis. Ms. Thompson, the District brought on
    two new contractors to take on 16 group homes. Several agencies
    had to help with this transition. Could you walk us through
    some of the steps you had to take?
        Ms. Thompson. Yes, I'd be pleased to do that, sir. Let me
    start at the end and work back to the beginning.
        The end was having people in place, providing services in
    legally licensed safe environments. To get there, each of those
    providers had to get an inspection from our Health Regulation
    Administration, and they had to the get the inspection on the
    day they were taking over. It could not be before they took
    over. That is just our regulation.
        Prior to them getting the inspection, they had to submit a
    Certificate of Occupancy, which means that they had to go
    through our agency that handles the building permits, which is
    normally a difficult process, but we were able to negotiate
    that properly.
        Before they got a Certificate of Occupancy, they had to
    have a signed lease for the facility that they were going to
    operate. Before they could have a signed lease, they had to
    have an agreement with the District which guaranteed them that
    they would have funding with which to pay the lease. To get the
    agreement with the District, they had to negotiate a budget and
    a contract with our Office of Contracts and Personnel.
        To negotiate the contract, first they had to respond to a
    public request for proposals. So all of this was a tightly
    organized, quickly moving train. But it had many, many, many
    stops it had to make along the way.
        In the end, everything came together well. It took my
    interagency coordination with the Medicaid Administration,
    Contracting and Personnel, Consumer Regulatory Affairs, the
    Health Regulation Administration, the D.C. Fire Department,
    MRDDA itself, and the advocate agencies and the court monitor.
    And it was a huge job to get done. And those agencies did a
    very good job following with me every single step.
        It was a nightmare but it was something that had to happen
    and I think the people will be better served by those folks.
        Chairman Tom Davis. Thank you.
        Mr. Gettings, what steps need to be taken, in your opinion,
    to develop an effective interagency agreement between the
    Medical Assistance Administration in the Department of Health
    and MRDDA in the Department of Health Services that would
    govern the management of Medicaid dollars for services for the
    mentally disabled?
        Mr. Gettings. I think that, first, there are plenty of
    models around in other States where that has been done.
        But the principles behind this, the management agreement
    between the two, are that you manage a unified budget across
    Medicaid and city dollars, that has a single focus on creating
    a sense of accountability for how the system is going to
    operate.
        Again, the problem that the District has faced in the past
    is not unique. Other States have faced exactly the same problem
    of saying we have a single State Medicaid agency that manages
    our Medicaid program, and we have a program agency that is
    responsible for making this happen.
        The task is to bring those things together and define in
    clear terms what the interaction between those two accountable
    agencies has to be, so that there is an absolutely unified
    approach to developing policy and funding services.
        Chairman Tom Davis. Thank you, very much. Ms. Morrison. Let
    me start with Ms. Bobby Walker. Does the city plan to require
    accreditation caregivers?
        Ms. Walker. We are looking into accreditation. We have a
    team looking at that. Our recommendation is that we do not
    pursue that in this next year. That is a very involved process
    in that it's very labor intensive. We can adopt standards and
    we can--in terms of our whole QA process we are going to be
    moving in that direction, but it's my recommendation that we
    not pursue formal accreditation. At least not this year.
        Chairman Tom Davis. Mrs. Campanella, let me ask you, when
    the city meets the court's requirements in the Evans case,
    services to class members will obviously be improved. What do
    you foresee the need for reforms that go beyond Evans'
    compliance to make sure non-class members receive adequate care
    and service?
        Ms. Campanella. Good question. Basically where we are
    focusing our efforts around quality is not at setting the bar
    at the floor, which is what we see the compliance with the
    Evans plan as defining the minimum standards, but going beyond
    that to begin to look at the kind of individually responsive
    services and individually supportive services that Ms. Morrison
    described earlier.
        So we have begun to focus on the basic assurance areas of
    health safety rights, safe environments, and other kinds of
    supports like that to really assist providers to think broader
    than just minimum compliance.
        Chairman Tom Davis. Thank you very much. I have more
    questions. I am going to go--although I may or may not make it
    back--I am going to turn the gavel over to Ms. Norton. If I
    don't get back, I want to thank everybody for this. We may have
    some other additional questions for the record. Again we don't
    like to get into these things, but given what has transpired
    and the length, and really the severity of the problem, we are
    going to continue to exercise some oversight. But I just want
    to thank everybody for being here today and trying to work to
    get this resolved.
        Ms. Norton [presiding]. Thank you, Mr. Chairman. The
    chairman does turn the gavel over to me. In the past I've
    always turned it back. I am kind of like a trustee in the jail.
    You know, you let the trustee have greater freedom because the
    trustee is not going to break out. One of these days I may have
    to break out. But because we have a bill pending, maybe that
    will be unnecessary.
        Let me start with what appeared to be a loss of confidence
    by the counsel in the ability of the agency to improve itself,
    taking the drastic step of denying funding. Was this a denial
    of increase in funding? Very harsh step considering the
    vulnerability of those involved.
        One, is this a denial of an increase in funding? And what
    is the effect?
        Mr. Bobb. Thank you. Well, we stated to city council that
    we have several requests them before them. One was a request to
    address the budget pressures in the current fiscal year, as
    well as a request for additional funding in the 2007 budget.
        We also during the course of our budget deliberation, have
    reduced the budget by approximately----
        Ms. Norton. You wanted funds for this fiscal year plus an
    increase next year?
        Mr. Bobb. That is correct. We need additional funding this
    current fiscal year, as well as additional funding in the 2007
    budget effective October 1st. And so we have been working
    through both of those issues with the city council.
        Ms. Norton. I thought the city council had made a decision.
    And what was the decision that was made?
        Mr. Bobb. They made one decision last week, which was to
    provide us with, I think, $10 million of one funding request.
    And that decision was made last week.
        We still have a decision pending before the city council
    with respect to the 2007 budget.
        Ms. Norton. So they have, in fact, given you $10 million
    that you wanted for this year's budget?
        Mr. Bobb. That's correct.
        Ms. Norton. And what made them decide to do that?
        Ms. Walker. If I could address that, having had to testify
    many times about the budget needs of the agency, the chairman
    of the Human Services Committee told us point blank that he
    withdrew an opposition to our funding request in view of the
    management changes that we made and the systems improvement
    plan and the mayor's and city administrator's commitment to
    stand behind the agency and to drive this reform.
        But the $10 million that was improved last week, we still
    have another close to $8 million pending before the council for
    this year. So, this year there is $18 million----
        Ms. Norton. Why were those funds needed?
        Ms. Walker. Well, there are several reasons. One, the
    agency received a budget cut last year for fiscal year 2006 and
    did not adjust its spending accordingly.
        So the budget cut of, there was a budget cut of $5
    million----
        Ms. Norton. Is that a budget cut or not as much money as it
    requested?
        Ms. Walker. Last year it was a cut as part of the budget
    process. But going in when you know your budget has been
    reduced $5 million, then it's the responsibility of the agency
    to just adjust its spending plan accordingly. But that didn't
    happen----
        Ms. Norton. Why didn't that happen?
        Ms. Walker. A management issue. We also had some unusual
    circumstances this year. The closure of the local forming group
    homes that has been mentioned before, which was written in the
    papers, what a bold step and necessary step, and I commend the
    former administrator for doing that. What that meant is the
    providers had a number of homes that were Medicaid-funded
    homes, the ICFMRs. When they come in as new providers, they
    have to go through the process to get certified again, which
    meant that for a period of--we are projecting 90 days and we
    are close to the end of the 90 days--to get them certified,
    then we have to take them off the Medicaid dollars and they get
    funded totally with local dollars. So that was another $4
    million total for that period of time.
        So that was an unforeseen expenditure but one we felt was
    necessary due to the performance of those agencies.
        And then the other primary driver of the budget issues this
    year was that, as Ms. Campanella and other advocates in our
    Evans parties push us to do, is to provide placements for
    clients in the least restrictive environment, and which we
    support, but the agency has done that irrespective of the
    funding available.
        And so decisions have been made, policy and practice
    decisions, that have not been consistent with the budget
    authority to fund them. And so we find that we have more and
    more clients who are in apartments, who need a lot of
    individualized services that our current waiver does not cover.
        Now, those are decisions that, you know, always have to be
    weighed out. But certainly if those are the practices an agency
    is going to undertake, then it has to have the budget authority
    in order to do that. So you have those things running, pushing
    the budget into a major deficit this year.
        Ms. Norton. Which brings to us the waiver. If what we are
    talking about is the Federal Government picking up part of
    services that otherwise you would be providing, I can't think
    of more of an incentive to try to get a waiver. What stands in
    the way of a larger Medicaid waiver?
        Ms. Walker. Well it's the process. It is a long and
    involved process----
        Ms. Norton. It is not the process.
        Ms. Walker. Part of it is----
        Ms. Norton. It is the same process for everybody in the
    United States. So it's not the process.
        Ms. Walker. The process should have been started a long
    time ago. It was started but it was wasn't completed. Here is
    where we are today. We do have the expert consultants on board.
    We have signed a contract to take us to the place where we can
    finally fully submit a completed application to the Federal
    Government to expand the waiver and----
        Ms. Norton. So somebody missed the process and the
    consultants are in the process now?
        Ms. Walker. Yes. Yes. There already has been an
    application. A large part of the application has been
    completed. There are two sections that have to be done, and
    that is where we needed the expert consultants----
        Ms. Norton. Are you going to seek this larger waiver or
    simply the renewal of the existing waiver?
        Ms. Walker. No. We are seeking a larger waiver that is more
    expansive and will cover more services and more hours for the
    types of services that our consumers need.
        Essentially, right now the local government is paying, like
    you said, a disproportionate amount under our current waiver.
    So we want to refine that waiver, have that expanded and that
    will be part of the renewal application for the waiver, so we
    would go in for renewal with the expanded waiver.
        Ms. Norton. I am very pleased to hear that. You owe that
    not only to these residents, you owe that to the taxpayers of
    the District of Columbia.
        Ms. Walker. I totally agree.
        Ms. Norton. Because they're picking up the rest. I am
    interested in that because I have put in a bill--I have a
    series of bills called the Free and Equal D.C. Series. When we
    got the increase in Medicaid, we still were left paying, as the
    District of Columbia, a larger share than any city in the
    United States, even New York, which is the only other city that
    pays 25 percent. We pay 30 percent. That is much better than
    before.
        But this bill seeks to put the District in the same
    position that any city would be in. So it asks that at least
    part of this be picked up by the Federal Government, as the
    quote states.
        Now, obviously, if the waiver process in the District is
    all out of kilter, that would seriously interfere with
    Congress, seriously considering my bill.
        I haven't heard anyone--I was out of the room for a moment,
    but I understand that no one has advocated receivership. Does
    anyone at the table believe that receivership is necessary at
    this time?
        Ms. Thompson. I only believe that would be necessary if Mr.
    Robert Bobb does not take over the agency and manage it as an
    internal receiver, as he has done with DYRS.
        Ms. Norton. Mr. Bobb, do you believe that the agency should
    report directly to you? MRDDA should report directly to you?
        Mr. Bobb. Technically it does.
        Ms. Norton. How technically?
        Mr. Bobb. We have the deputy mayors work directly with
    these agencies with respect to their daily operations, but at
    the end of the day they are accountable to me and the mayor.
        Ms. Norton. They're accountable, yes. I am now talking
    about--would you speak to Ms. Thompson's notion--is it your
    belief that improvements would be made--let me give you some
    background here. A number of us have some bills over here
    involving FEMA, following the Katrina disaster.
        None of them--all of them--they differ somewhat, but all of
    them believe that FEMA should report directly to the President
    of the United States and should not have to go through any
    bureaucracy; in other words, if an agency has a mission that is
    either difficult or important, it may be that what would
    otherwise make sense--and here we have the Department of
    Homeland Security--would otherwise make sense, may not make
    sense for this particular agency. Given the long history of
    problems in this agency I ask whether or not Ms. Thompson's
    suggestion should be considered?
        Mr. Bobb. Yes, it definitely has been under consideration.
    Let me just say we had a similar situation----
        Ms. Norton. I know that is putting a lot of, I don't know
    how much you can put on one person but you know, that is like
    saying I don't know how much I should put on the President of
    the United States. It's his job to make sure that it works, so.
        And I recognize, Mr. Bobb, that you are the real problem
    solver in the government. I know from firsthand experience.
        So I ask you, not only as a structural matter, I have run a
    big troubled agency in the Federal Government. I ask you as a
    pragmatic matter, is this suggestion feasible?
        Mr. Bobb. Yes, it is feasible.
        Ms. Norton. So you are considering doing that?
        Mr. Bobb. Yes, we are considering.
        Ms. Norton. Is it likely to happen?
        Mr. Bobb. After consulting with the Mayor we will be able
    to say, what we did, just as a point of contact, what we did
    with the Department of YSA, the former Youth Services
    Administration which has been in receiver for 20-plus years as
    well, is while that agency reports directly to the Deputy
    Mayor, I have an internal receiver that works with me and the
    Mayor's personal attorney, executive lawyers for the Mayor. So
    I have a lawyer that works for me that helps to move the
    reforms forward with the director. And then I meet personally
    with the plaintiffs in the case.
        And so I am directly engaged with the lead counsel for the
    plaintiffs in the Jerry M. case, for example. So to that extent
    I am very, very involved in pushing the reforms in that case.
    And so we are looking at a similar model with respect to this
    agency.
        Ms. Norton. That is very wise if you want to avoid
    receivership. Does anyone else believe that receivership is,
    should or should not be considered or appointed?
        Ms. Campanella. Ms. Norton quality trust fully understands
    why the plaintiff's attorneys have filed for receivership in
    this case. As I stated in my testimony, the situation for
    people in the city is very troubling.
        There have been continued promises, continued deadlines
    missed, and, unfortunately, continued harm that has come to
    people who rely on the service system here. So while we are
    very encouraged by some of the things that have happened, the
    time is past for when we can actually wait for some sort of a
    solution. As we all know, receivership takes time to work
    through the system.
        At such time that considers--receivership is actually
    considered by the courts, the substantial administrative
    changes have been made by the district, and possibly we can
    reconsider at that point, you. But at this point, the needs of
    people with disabilities in the District of Columbia are too
    significant and not being supported enough for us to say that
    pursuing receivership is not a reasonable course of action.
        Ms. Norton. So you favor receivership?
        Ms. Campanella. I favor the course of action in seeking
    receivership that the plaintiffs have taken.
        Ms. Norton. You favor the shot across the bow in applying
    for receivership, in hoping they get their act together so the
    court will not have to do so.
        Ms. Campanella. Again, I am going to say based on my 4
    years of experience in the District of Columbia, again, we have
    worked very seriously and we are very committed to working in
    concert with the District, Ms. Brenda Donald Walker, and at
    various times we have seen many players change. I don't
    question the earnesty of any of those folks. But the bottom
    line and the actual track record remains that some serious and
    significant changes have not been made as evidenced by where we
    are today with the waiver. So yes, given the situation as it is
    today, we do support the filing for receivership.
        Ms. Morrison. Ms. Norton, obviously from my testimony, I am
    here representing an organization that defines, measures, and
    improves quality for people with disabilities.
        And we would like to say that receivership or no
    receivership, it really won't matter if we don't start looking
    at outcomes for individual people, if we don't look at being
    responsive to people rather than layering different levels of
    organizational process and playing the compliance game.
    Bringing in a receiver that would not pay attention to
    individual personalized outcomes would only add another layer
    and make it even more difficult to get things done.
        So I think the issue of paying attention to personnel
    outcomes, measuring that, and moving forward in designing the
    system based around what people with disabilities say is
    important to them.
        Mr. Gettings. Ms. Norton, I would just add to that, having
    watched situations in which the courts have intervened in such
    a radical manner to appoint a receiver, that one of the things
    that has to be taken into account is, what is the end gain?
    Where does accountability ultimately reside? And serious
    situations call for serious interventions.
        And I agree with Ms. Campanella that if you look at the
    testimony that is presented to the court, it certainly
    justifies some radical interventions to correct the situation
    as it exists for a very, very long period of time.
        At the same time, I don't think a receivership should be--
    is a solution, unless you have a very clear plan for how
    government is going to reassume responsibility. So the best of
    all possible courses of action is that you avoid it. And I
    think, I hope that would not happen in this situation because
    it carries----
        Ms. Norton. Receiverships don't operate that way. They are
    open-ended and they end when the court says they end. And it
    could be years and years, and we know because we have been
    through that before. I am agnostic on it.
        Let me ask the Members of the panel from what you have head
    here today, for example, that they have hired a consultant,
    that they think they are going to get a comprehensive Medicaid
    waiver, does anything you heard here today indicate to you that
    a receiver may well not be necessary?
        Ms. Campanella. Again, let me start. I think, again, and I
    included in my testimony, a commendation for Deputy Mayor
    Brenda Donald Walker, because I think she has taken on a very
    serious job with a very serious approach and has begun to
    organize people in a way that would address some of these
    significant issues.
        I am glad to hear that they have the consultants on board
    and they're going to pursue the new application. But, at best,
    we are looking at implementing a new expanded waiver in the
    fall of 2007.
        Ms. Norton. That would happen whether or not there is a
    receiver, wouldn't it? Because if you got to have--the court
    can't mandate or won't mandate the Medicaid--more comprehensive
    Medicaid waiver, it would have to work it through as well in
    order to decide, I mean, what I am saying is I don't see what
    you are saying has to do with receiver.
        When it would start, when the waiver would start, yes, and
    over here it is, here the Federal Government, it's slow as
    molasses. But you have--D.C. hasn't even gotten it in and the
    taxpayers of the District of Columbia are paying for what the
    Federal Government should be paying for. And the expanded
    waiver has enormous implications for the improvements that you
    are indicating. So the only question about the receiver end and
    Medicaid is whether or not the receiver facilitates that or
    not. You could argue that the receiver delays that, because I
    can say without fear of contradiction that the agency is quite
    unlikely to give a Medicaid waiver while something is in court.
        Ms. Walker. Ms. Norton, if I could respond to this whole
    receivership and what we are doing, I ran an agency that had
    been under receivership. And when we took over the agency in
    2001, it was after they had negotiated a settlement to end the
    receivership and the mayor elevated this to a Cabinet-level
    agency--we took over that agency and it was in shambles. There
    were no structural foundations. We had to build everything from
    scratch.
        And the same thing is true about the Department of Mental
    Health which exited receivership at the same time. So we are
    vigorously opposing the notion of receivership.
        Ms. Norton. I understand that. But the point is--what my
    question is, in order to get the comprehensive Medicaid waiver
    it does seem to me you would have to show such substantial
    improvement. It may even be a proxy for----
        Mr. Gettings. That is very true, because essentially what
    the city----
        Ms. Norton. Proxy for a receiver.
        Mr. Gettings. Is requesting a special dispensation under
    Medicaid policy to gain that waiver and, yes indeed--and that
    is why I said in my written testimony, there is a lot of work
    to be done in order to get to the point where you can do that.
    I am very encouraged by the commitment that I have heard here
    today and I hope we can move ahead rapidly on it.
        Ms. Norton. I don't see anything inconsistent with what has
    been said here. And, Mr. Campanella I don't know if you had
    wanted to say something further.
        Ms. Campanella. I would just add I am encouraged by the
    focus on the new application. I would encourage, and I have
    encouraged, this administration to continue to be focused on
    what can change today about how we implement the local rules
    that govern the waiver program. Because we believe there is
    potential there to make some improvements long before 2007.
        Ms. Norton. In the chairman's opening testimony, he
    detailed some of the abuses that brings a matter like this to
    the attention of the Congress, these, of course, are anecdotal
    but they are so horrendous that even a few of these leads
    people to believe that there is something wrong that has not
    been reported. He spoke about charges of sexually abusing a
    patient or burning a patient.
        But what was most, most troubling was the part of his
    opening statement that said that the monitor had said that for
    a period of over a year the District failed to notify the
    providers where these residents lived or the results of the
    investigations, even though these investigations were conducted
    by the District's own reviewer.
        And then, of course, he said--here I am quoting the
    chairman--as a result--no, no I am not quoting the chairman. He
    is quoting the article I think. As a result, corrective actions
    were never discussed, let alone implemented or evaluated.
        Yes, Ms. Thompson.
        Ms. Thompson. Congresswoman Norton, in 2004 when I was an
    employee of MRDDA, my job at that point was to work with the
    Evans compliance piece. And I followed a committee called the
    Mortality Review Committee, which began at that time to share
    those evaluations and recommendations and the actual reports
    from Columbus with the providers, the hospitals etc.
        I was moved from that position to work for the deputy mayor
    to oversee the health care plan.
        In late April, early May, I was sent back to MRDDA as the
    interim administrator, at which time, by the way, we only had
    about a month's worth of funding in the pot. When I got back
    there, there were so many things to fix that it took me a few
    months to recognize that the committee had stopped meeting when
    I left.
        So I reinstituted it in November 2005 and broadened it to
    include the monitor staff, case management staff, the quality
    trust, and many others. So we put a process in place to ensure
    that these recommendations and reports were distributed
    appropriately to everyone who touched the client at the time.
        So that has restarted----
        Ms. Norton. You are telling me that these reports are now
    always made available?
        Ms. Thompson. Now they are. Now they are.
        Ms. Norton. All right. Let me go to what is my real concern
    here. You would think that is the least that could be done.
        I noticed that in Ms. Campanella's testimony--I am not
    interested--of course, I am interested in finding out what
    happened and preventing it and so forth. But you see it should
    be, if somebody has been seriously hurt you wonder how, what
    the agency is doing to make sure that doesn't happen. And she
    says in her testimony, she speaks about the advocate. ``Each
    person by law is entitled to an advocate,'' and says that there
    is no dedicated funding, although funding has been included in
    the current budget request. Now, let me ask, because the point
    here is to have somebody who will watch over me, as they say,
    ``somebody to watch over me.''
        And very often there is no relative, and even if there is
    somebody, the relative may not feel it is his responsibility to
    perform this function.
        Is the advocate the best way to prevent this kind of abuse,
    the fact of actually going and monitoring the residents often?
    Is there now dedicated funding? Does every resident in one of
    these group homes have an advocate?
        Ms. Thompson. Ma'am, the answer to the last part of your
    question is no. Every person in those group homes does not have
    an advocate. A critical function that I think when we are
    really sort of dancing around the edges is the role of active
    and advocacy-based case management where the intent of case
    management is around advocating for the client as though that
    person is your best friend or your family member.
        And until that intent of case management is properly
    developed----
        Ms. Norton. I am not talking about intent of case
    management? Are you talking about case workers?
        Ms. Thompson. Yes, I am.
        Ms. Norton. Are there sufficient case workers? Once I hear
    you talk about case workers, my eyes really begin to roll,
    because it's so hard to find people to deal with people in many
    different kinds of situations. So, is the answer that every
    person should have a case worker that comes so often that, in
    fact, burning somebody or sexually abusing somebody is
    deterred?
        Ms. Thompson. I think that is part of the answer, Ms.
    Norton.
        Ms. Norton. How often do case workers----
        Ms. Thompson. They are supposed to see people as far as I
    know now, at least once per month. But that is the floor. That
    is not what real case management advocacy is about.
        Ms. Norton. What is real case management advocacy about? I
    am interested in somebody watching over. I only have one
    question. If they know somebody is, if they knew I was going to
    come in there very often, they are less likely to harm the
    person I am coming to see. And all I am asking is, and when you
    tell me about case management and case workers, then I really
    get scared because we have had hearings on foster children, we
    know nobody is going into social work. I don't want to go
    through that one again.
        So, I was caught by this notion of an advocate because I
    can't ask the District to do the impossible.
        Mr. Gettings. There are several issues that are being
    raised here. One of them is the issue of an individual legal
    advocate. That is through the Superior Court.
        That's not budgeted as part of the city's budget, and when
    Ms. Campanella talks about a budget request there is a budget
    request that has gone forward to the superior court to put in
    funding for those advocates. That is an act of Congress. It is
    not an act of the city government, by the way.
        Ms. Norton. But what does the advocate do and how often
    does the advocate come?
        Ms. Campanella. The court-appointed advocate would work
    under the supervision of the D.C. Superior Court Family
    Division. And the idea in their volunteer advocacy program is
    that it would introduce into the lives of people with
    disabilities, who may not have family, someone who is committed
    to going and visiting that person and staying involved in that
    person's life, over time.
        Ms. Norton. Mr. Bobb, please. I am trying to get, how many
    advocates do we have? And how often do you believe the advocate
    should come in order to have at least a deterrent effect on
    abuse?
        Ms. Campanella. Again, my best estimate at this point is
    for an estimate of 1,200-plus people who should be accessing an
    advocate. There are around an average of 200 advocates
    available.
        So they assess AREAs. Any people that don't have an
    advocate.
        The advocacy program, as it currently exists, is not
    supervised. It has a half-time clerk assigned to it, and it is
    not really staffed to oversee any of the recruitment and
    supervision activities that it would need to make it a
    functional program.
        Ms. Norton. Now let's get to the funding. You say in your
    testimony that there hadn't been dedicated funding in the
    budget request. Mr. Bobb or Ms. Walker or Ms. Thompson, again,
    is the money--budget--has this been approved in a budget which,
    by the way, is already over here? Then, Bob, the answer to the
    question is no. We don't have this as a ``be candid,'' this is
    the first time I have known, seen this D.C. law. You know this
    particular code. And I don't know that if this is a requirement
    if it's a requirement that the D.C. government, and no one has
    called this to my attention, if it is a requirement of the
    courts. And we should be advocating with the court to provide
    this funding.
        Ms. Campanella. Again, Ms. Norton, just to clarify, we have
    been advocating over the past 4 years with the D.C. Superior
    Court to acknowledge and figure out how to address and
    implement the responsibilities associated with this.
        It is my understanding that Judge Rufus King in the D.C.
    Superior Court has included just under $1 million in the budget
    request that was sent to Congress for the superior court.
        Ms. Norton. In the court budget.
        Ms. Camanella. The court budget. Yes, because this was
    supervised and overseen by the D.C. Superior Court.
        Ms. Norton. And these are volunteers?
        Ms. Campanella. It's a volunteer advocacy program. Again it
    was designed back in, I believe, 1978 when the law was
    designed. The local D.C. law is the Citizens with Mental
    Retardation Rights Act of 1978, I believe. And it defines
    individuals' rights to have access to an advocate to help them
    understand what's happening to them. And when this program
    works well, and as we have seen at least in a few individuals,
    it introduces again into the person's life somebody who is
    there, that cares about them, and who will ask the hard
    questions not because they're paid to, but because they just
    care about the individual. Which is a significant safeguard.
        Ms. Norton. I want to know where we have something
    involving Federal funding, I do wish people would be in touch
    with me. I am very pleased that the court, the court has been
    very vigilant now, particularly now that we have done that
    court, put a lot of money into that court. But I had no idea,
    and I am very pleased that Judge King has indeed put this in.
    But I didn't even know about it.
        This is the best way, short of the complicated notion of
    case management that the District still has to do to assure
    somebody will be there for the advocate, and perhaps we can
    prevent some of the incidents that have been in the paper and
    that were----
        Mr. Gettings. It's a piece.
        Ms. Norton. I am not suggesting--look, we have discussed
    the whole--excuse me--darn thing. And you know, it's very nice
    for us to talk about structural stuff. I am trying to deal with
    the fact that these people need to be taken care of right now.
        So while they're getting their act together--and nobody
    suggested an advocate or even a case worker can do this job--
    but meanwhile people are sill sitting in these group homes now.
    And I picked this up, really, from Ms. Campanella's testimony,
    because it seemed to me that even what you've described, Ms.
    Thompson, going in and catching it, going back and evaluating
    it after it's done, is a terrible thing to have to do. There
    should be very few of those.
        So what's the answer? The answer is I am at the mercy of
    this group home, with nobody to watch over me. Then of course,
    I have no confidence in myself that there will not be some
    minimum wage person untrained or whatever, who may abuse
    somebody.
        But, let me ask you, is there another way--other than the
    advocates or redoing the whole case management which they are
    in the process of doing--is there another way, other than the
    advocate to get this kind of frequent oversight by one person
    dedicated to the client--or is this really the best way to do
    it and deter it? Because if there is another way, I want to
    know about that other way, too.
        But if it's let's reform the system, yes, of course. But
    meanwhile there are people that could be abused today,
    tomorrow, and the next day while you're reforming the system
    which hasn't been reformed in a very long time.
        Ms. Thompson. In today's terms I think that is probably the
    very best way to go right now.
        Ms. Norton. Let me tell you one thing. That's a Federal
    matter because the courts come under us. I am going to be in
    touch with Judge King. They have run their programs well. Do
    you believe this $1 million funding would be enough for every
    resident in a group home to in fact have an advocate?
        Ms. Campanella. Again, based on what I've seen, I don't
    know if it is totally enough but I think it's a good--it
    provides a good foundation and starting point.
        Ms. Norton. I'm going to call Judge King and ask him. And
    if it's not enough, the budget has beautifully gone through the
    House without any attachments. When they were cutting to
    smithereens, we were able to keep things from being cut that
    were critically needed. But the budget has not yet gone through
    the Senate.
        So I would like you to--this is my counsel. I would like to
    know by the end of the day from Judge King, whether or not the
    million dollars is enough to cover an advocate for each of the
    clients? How many are there, please?
        Ms. Campanella. Approximately 1,200 people that we estimate
    need an advocate.
        Ms. Norton. That would be the total pool.
        Ms. Campanella. There is approximately just under 2,000
    served by MRDDA Service System but I think it is only certain
    people that are in residential services that need the advocacy.
        Ms. Norton. But Federal funds a lot of this may have
    happened, and I am just pleased to know about it. I understand
    that there is a consulting firm that investigates these deaths.
    But the district has been hammered because these reports are
    not made public. I don't understand what the, ``privacy
    concerns'' would be. Somebody has been killed while literally a
    ward of the State. That is the worst intrusion of privacy I
    ever heard of.
        But I don't understand the privacy concerns. Once there is
    a death, that is a matter of public record, I thought. No
    matter who it was, there is a death. So I want to understand
    why it is that this is not routinely disclosed; if it would be
    disclosed with, for example, the investigative work that Ms.
    Thompson has described, and what is the state of that?
        Because that makes a city look worse than ever, if the
    people get killed or abused and get investigated and then
    nobody is told. Then you get the press going after you, and you
    get people no longer having confidence in you because you don't
    report things that are--that have happened are untold. Look,
    something is going to happen that is untold. This is not a
    perfect world. And it's been investigated and you can then at
    the same time talk about what the investigation shows and what
    you have done. I don't see that the city is going to be held to
    the standard of perfection. It is held to that standard though
    when people only find, when the press or somebody else hammers
    them. So I would like to know if there is a systematic way to
    report the deaths, particularly the deaths or other such
    concerns along with what the city is doing to correct it.
        Ms. Walker. The answer is, yes, Ms. Norton. There is a
    systematic way. There is a citywide fatality review committee.
    The debate about the records is the amount of redacting or
    protecting the confidentiality that is tied into a lot of other
    legal issues such as HIPAA, the family members. And I think,
    though, that we can certainly respond more openly with the
    council and our other stakeholders in this, even though you can
    redact and protect an individual's confidentiality, we
    certainly need to be held responsible for reporting on what the
    findings were, what we have done in response, and if there are
    certain providers where you have multiple occurrences, then we
    have to be forthcoming with that information. And we are still
    working through that with the city council as far as the level
    of information that is provided. It is pretty much of a legal
    battle.
        Ms. Norton. Well, if it's a legal battle, then of course,
    what can be reported should be reported.
        Ms. Walker. Correct.
        Ms. Norton. The public has a lot more confidence when the
    government comes forward and reports on it itself than it does
    when a FISA or something has to be filed by the press, who can
    always then find out. And apparently the press has found out.
    So I don't know what these privacy concerns are if the press
    can find out.
        Let me close with this hearing, I am very pleased with the
    notion of this advocate, that restores some confidence in me
    that a system that is spread all out in the city, nobody can
    possibly know what is going on every moment, the best you can
    do is to try to deter it. And if you know that somebody is
    coming in there, it does seem to me the deterrent effect can be
    extremely important here.
        There was a report from a hearing, a recent hearing, that
    47 out of 1,800 patients get the, ``requisite monthly visits
    each year.''
        What is that about? Is that about the case management
    system?
        Ms. Thompson. Yes, ma'am.
        Ms. Norton. Is that, in turn, dependent upon hiring more
    case workers? Are we back into the revolving issue that has
    never been solved and I am convinced will never be solved?
    Unless we can get to the point where we can get something like
    what we have in the school system, paraprofessionals or
    something, you will never convince women--and that is who you
    are talking to--who can now be anything they want to be, that
    they ought to take the low pay that goes along with being a
    case worker, which means you have some sort of social work
    background, rather than using that same background on something
    that pays better.
        So I would like to know what you are going to do about the
    case worker personnel problem. Or is there one? Maybe you don't
    have that problem.
        Ms. Walker. I think it's a matter of training
    accountability, and effectively----
        Ms. Norton. I am asking one question so we won't go on. The
    chairman is back. He said my 5 minutes were up.
        The Chairman. Almost. Almost.
        Ms. Norton. I am asking--I am talking about one visit, 47
    out of 1,800 patients got the required one visit per month. Now
    I am trying to deal with part of this through the advocate.
        But if we are talking about case workers, then my question:
    what are we talking about, case workers?
        Ms. Walker. Yes. We are talking about staff case workers
    from MRDDA.
        Ms. Norton. If we are talking about case workers, then
    unless you have had something to happen to the District that
    has not yet been reported, there is a severe shortage of case
    workers.
        Ms. Walker. MRDDA actually has an adequate number of case
    workers.
        Ms. Norton. Who, in fact, visit once every month.
        Ms. Walker. Yes. Their caseload ratio is among the lowest
    in the country.
        Mr. Gettings. Absolutely.
        Ms. Norton. Go right ahead.
        Ms. Walker. This is why I get to accountability and
    training and oversight----
        Ms. Norton. Training? Just going out there once a month?
        Ms. Walker. Maybe it's accountability and oversight. And I
    understand the issue about not having enough case workers and
    social workers. I have had that with CFSA. That's not the case
    here.
        Ms. Norton. Are these trained social workers, do they have
    to have a college degree?
        Ms. Walker. No. But they do have a college degree. No.
        Ms. Norton. They don't have to have a college degree, it
    seems to me. That is why I talk about paraprofessionals or
    something----
        Ms. Walker. I believe they fall in that category. Ms.
    Thompson would know better about the requirements.
        Ms. Norton. You think the reason they have not been going
    out once a month, if they had been going out once a month maybe
    we would have less of what was in the chairman's testimony. But
    between the caseworkers going out once a month, and we got
    enough case workers, and the advocates going and spelling when
    they go out does seems to me to go a long way toward preventing
    abuse and deaths.
        Why have they not gone out? That doesn't take training. It
    just says go out there and report whether you have gone and
    sign this thing here that you have gone out there.
        Ms. Walker. I have to turn it over to Ms. Thompson.
        Ms. Thompson. Basically I think the reason, I think what is
    two things: you have somebody go out and come back and don't
    report that they have been out. I have run into that myself in
    the homes. And then I go back and I check on the internal
    information management system and they haven't put their notes
    in. And then the other issue is the ones that just don't go
    out. And they don't go out. It was the building was wrong or
    they didn't know who they were supposed to see, or they had no
    way of getting there because MRDDA doesn't provide the
    transportation.
        There is, again, the issue of caring and intent, and
    understanding what case management is supposed to be about and
    wanting to do that. And wanting to have a good government job
    is one thing, and wanting to be a good case manager is, say, a
    separate thing. And those two just don't meet right now in
    MRDDA's case management work force.
        However, when I left I was hopeful, because I was beginning
    to see the turnaround, the change, in case management interest.
    They were beginning to want to go out, and I mean, that is
    where it comes down to.
        Ms. Norton. Maybe that is what Mrs. Walker meant when she
    said training and, of course, accountability.
        Let me ask one more question. This comes from Ms.
    Campanella's testimony. I am very leery of anecdotal evidence
    but they do tell us things. And she spoke about a woman who was
    found living in a dilapidated apartment, so dilapidated her
    health was threatened. And then she says that despite intense
    efforts by the advocate and the personal intervention from the
    court monitor and the administrator of MRDDA, it took nearly 7
    months to successfully transition this woman into a new living
    arrangement.
        Are you talking about somebody who was going to be put into
    a new apartment?
        Ms. Campanella. Yes, ma'am.
        Ms. Norton. That may explain it all, Mrs. Campanella,
    because if you are trying to find a new apartment for anybody
    in the District of Columbia, the average person in the District
    of Columbia, good luck. Because at least I think MRDDA may be
    willing to pay rents that the average person here can no longer
    afford.
        And then you are trying to place somebody in an apartment
    who is so troubled that she was living mired in health risk in
    her own apartment. How do you find apartments for people like
    that in the District of Columbia?
        Ms. Thompson. Ma'am, let me respond a little. This person
    apparently has lived on her own with her husband for a number
    of years. Their living situation was deplorable from what I
    found myself. I think that there was some communication issues
    back and forth between what they felt they would be obligated
    to submit to intrusiveness as opposed to their choices to live
    the way they were living.
        And it was a matter of education and urgency and diplomacy
    on the part of case management at MRDDA. And when Mrs.
    Campanella's staff and the court monitor staff brought it to my
    attention--I worked with Mr. Brian Willbom and we were
    quickly--when we had our hands around it--we were quickly able
    to convince them, yes, you don't want to live there when you
    could live here.
        And guess what----
        Ms. Norton. You were able then to find--it was a question
    of them not wanting to live----
        Ms. Thompson. Yes, it was a communications issue, I really
    believe, but it was resolved.
        Ms. Norton. I was concerned about that because if in fact
    this so troubled a person anywhere she lived, might in fact get
    her in the same situation. I think it would be hard to find a
    living arrangement for her in her own apartment even if she
    were able to take care of herself. But then maybe somebody
    coming in and helping her would be all that was needed.
        Ms. Campanella. It underscores and illustrates many of the
    things that have been discussed here this afternoon that need
    to be urgently addressed about case management and
    communication.
        Ms. Norton. I compliment Mrs. Thompson that she was
    willing--they went all the way to the top and she was willing
    to step in.
        Ms. Campanella. We do too.
        Ms. Norton. Testimony, very, very helpful. You heard from
    the Congress; I am sure you don't need to hear from us again.
    Thank you very much, Mr. Chairman.
        Chairman Tom Davis. Thank you all very much. I want to
    thank you for being here we look forward to working with you as
    we try to get this program in shape. This hearing is adjourned.
        [Whereupon, at 11:55 a.m., the committee was adjourned.]
        [The prepared statements of Hon. Henry A. Waxman and Hon.
    Diane E. Watson follow:]

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