[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



                                 ______

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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:]

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

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    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:]

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    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:]

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    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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