Some important admission criteria and assessment procedures were not covered sufficiently in the County's contract with Sound Recovery or in Sound Recovery Center's protocols. In fact, the admission criteria were not stringent and the assessment procedures for routine staff functions such as breathalyzer tests and vital signs were not comprehensive. As a result, clients who had very high breath alcohol levels, clients with no breath alcohol readings, and clients with health conditions were admitted to the sobering facility without frequent monitoring of their conditions.

It should be noted that experienced sobering programs have established comprehensive procedures and rigorous admission criteria (e.g., maximum breath alcohol levels, etc.) to facilitate the referral of clients at extreme levels of intoxication or with serious health conditions to appropriate medical providers rather than to the sobering facility. Clients who were medically approved for later admission were also monitored more frequently than clients without abnormal signs or symptoms.

Sound Recovery Center's client monitoring practices were also inconsistent and deteriorated since the facility opened. Vital signs were taken at regularly scheduled intervals for 98.1% clients admitted during June 1996, but for only 25.6% clients admitted in November 1996 and May 1997 based upon the client records sampled. Furthermore, the sobering staff did not have continuous visual access to clients from a central point as required by DASAS contract. Walls separated the worker's stations from the main sleeping areas, and a second sleeping area was located on another floor.

The audit recommended that the Sound Recovery Center develop, for DASAS' review and approval, comprehensive policies and protocols for the sobering center that include more stringent admission criteria, clear guidelines for routine monitoring and repeated breath alcohol and vital sign assessments; and step-by-step procedures for performing routine procedures. In addition, Sound Recovery Center should reconfigure the physical structure of its sobering facility (e.g., remove walls, install windows, etc.) so that sobering staff have visual access to the sleeping areas and provide better on-site supervision to ensure that contractual policies and procedures are fully adhered to by all staff. Finally, DASAS should improve its oversight of the sobering operations until full compliance is achieved with contractual requirements.

Finding 2. One deceased client should have been referred to a medical resource rather than admitted to the sobering facility.

Three client deaths occurred at Sound Recovery Center between June 1996 and May 1997 and the Medical Examiner determined that all three deaths were accidental. However, one deceased client should have been referred to Harborview Medical Center rather than admitted to the Sound Recovery Center's sobering facility based on the protocols set forth in of the contractual Statement of Work for Sobering Services. The Statement of Work identifies a series of abnormal signs and symptoms as criteria for referring clients to Harborview Medical Center (HMC) for medical evaluation, and the requirement for staff consultations with HMC's triage nurses and the designated lead sobering staff if abnormal symptoms are identified.

One deceased client complained of two abnormal symptoms upon entering the Sound Recovery Center, according to the client's record. Although the sobering worker discussed a possible referral to HMC with the client, the client declined the referral. However, the sobering worker did not consult with qualified HMC medical personnel or Sound Recovery Center lead personnel as required in the contractual Statement of Work for Sobering Services.

Additional contractual compliance issues were noted in the deceased clients' records. One client's blood pressure was taken three hours after admission, and no breath alcohol levels were recorded on the client intake forms for two of the three clients. The delay in assessing clients' blood pressure and breath alcohol levels was significant from both a health perspective (blood alcohol levels generally continue to rise within the first hour or two after admission) and contractual standpoint.

The audit recommended that Sound Recovery Center adopt the policies and procedures established by the model sobering programs, and routinely discuss unique client cases during staff meetings to reinforce the importance of team and Harborview Medical Center consultations, so that clients with abnormal symptoms are appropriately referred for evaluation. DASAS and Seattle-King County Department of Public Health officials should also encourage Sound Recovery Center's full compliance with the contractual requirements through regular monitoring of the sobering operations, clear communications regarding operational improvements, and immediate corrective action for unsatisfactory work performance.

Finding 3. Sound Recovery Center's Hiring, training, and oversight practices were insufficient, and improved access to medical resources was required.

Sound Recovery Center sobering staff were not sufficiently trained in sobering operations, were not well-managed, and did not have immediate access to qualified medical personnel. In fact, sobering workers were not formally trained until February and March of 1997 because Sound Recovery Center assumed that the newly hired workers, many of whom were former DASAS employees, were fully trained and experienced. However, the former DASAS employees were not trained to perform autonomously, and without easy access to medically trained staff in their former positions. Consequently, the sobering staff did not consistently follow admissions, monitoring and records-keeping procedures at the Sound Recovery Center.

Sound Recovery Center's performance during the past year was also constrained by the lack of access to qualified medical personnel. Sobering staff admitted clients with extremely low temperatures and blood pressures to the sobering facility. According to a HMC Consulting Nurse, one decreased clients' low blood pressure reading combined with convergent systolic and diastolic blood pressure readings would have clearly signaled medical personnel that further evaluation was necessary.

Finally, rapid hiring of staff without reference checks was another issue that impacted the Sound Recovery Center's sobering operation. While Sound Recovery Center currently verifies references for new hires, four unqualified individuals were hired to work as sobering supervisors and staff during the past year.

The audit recommended that Sound Recovery Center develop detailed policy and procedures manuals for easy staff reference. Breath alcohol levels and vital signs should also be printed on intake forms, and admission standards should be clearly posted for easy reference during the admissions process. In addition, Sound Recovery Sobering Center management should review intake assessment, monitoring, referrals, and documentation practices with staff on an ongoing basis, and should monitor staff practices and client records to confirm that all staff are effectively trained.

The audit also recommended that the Sound Recovery Center co-locate the sobering services with a medical detoxification service, or replace the sobering supervisor and lead personnel with medically trained (EMT, LPN, etc.) personnel. Also, Sound Recovery Center should immediately complete background and reference checks for all sobering facility personnel.

Finding 4. Sound Recovery Center did not have sufficient management controls nor demonstrate full compliance with contractual objectives.

DASAS' contract requires Sound Recovery Center to provide sobering services to a minimum number of clients per day and provided reimbursement based upon the number of clients served per day. The Sound Recovery Center was also contractually required to submit monthly reports to DASAS. However, the reports submitted to DASAS by the Sound Recovery Center were inaccurate and contained conflicting client counts. In fact, the monthly client counts varied from 10 to 204 admissions. In addition, the monthly reports indicated that Sound Recovery Center did not consistently meet its performance objectives.

Nevertheless, the reports were used by DASAS as the basis for reimbursement, and DASAS fully reimbursed the Sound Recovery Center every month. While an effort was made to reconcile the sample 1997 monthly reports, the frequency of the errors in the daily census suggested the need for a full audit of the Sound Recovery Center's records by DASAS.

The audit recommended that Sound Recovery Center develop specific record management procedures that are consistent with the DASAS contract; provide appropriate record-keeping training for staff; and verify that management reports submitted to DASAS are accurate and reconciled. In addition, DASAS should periodically audit Sound Recovery Center's management controls and records to ensure that accurate reports are produced and monthly performance objectives are met.

Updated: 06/24/02