Alternatives to Abortion subcontractor records show history of violations
Over the past five years, evaluators have found violations at state-funded subcontractors for Texas’ Alternatives to Abortion Services Program, which reimburses nonprofits — typically faith-based groups — to provide mentoring, counseling and material assistance to pregnant women.
But while those site visits were conducted by a contractor for the state, the Texas Health and Human Services Commission (HHSC) has never conducted a review of its own during the life of the program, according to an HHSC spokeswoman.
Evaluators from the nonprofit Texas Pregnancy Care Network (TPCN), which conducts the site visits, found at least one violation — not counting billing errors — during more than half of their pre-announced site visits to subcontractors, according to documents obtained by the Texas Independent.
Funding for the Alternatives to Abortion Services Program was upped from $4 million per year to $4.15 million, even while the rest of the state budget was slashed, particularly in the areas of family planning and community mental health services.
Texas’ program is modeled after a program pioneered in Pennsylvania in March 1996, using a contractor called Real Alternatives, which is also a consultant to TPCN. A spokesperson for the Pennsylvania Department of Public Welfare said, as in Texas, the Pennsylvania state government has never conducted its own evaluation of subcontractors. The spokesperson directed further inquiries about the Pennsylvania program to Real Alternatives, which did not return requests for comment.
In Texas, TPCN evaluators conduct “initial site visits” before subcontractors begin receiving state money, as well as yearly “service provider site monitoring” after subcontractors are receiving state funds for serving clients. According to the TPCN manual for service providers:
“The Evaluator will conduct the site monitoring based on the criteria contained in the Site Monitoring Review Checklist as approved by HHSC. This checklist is provided to all service providers prior to a scheduled site monitoring review to assist with their preparation for the visit and to maximize the time spent.”
Official records of TPCN follow-up visits — conducted after they’ve begun receiving state money — show violations ranging from fire safety to possible breaches of client privacy. During 15 percent of inspections (which were not undercover visits), subcontractors had failed to separate and label spiritual and educational materials properly.
For this investigation, the Texas Independent collected site visit reports from June 1, 2006, through the end of February this year.
All but one of the state’s 33 subcontractors has overt religious affiliations, as the Texas Independent previously reported.
A copy of the TPCN manual was retrieved from subcontractor Austin LifeCare’s website, and has since been removed from the site. The manual states that an HHSC employee may accompany the TPCN evaluator during the site visits, though TPCN records show no evidence of that taking place.
State Rep. Garnet Coleman, D-Houston, questioned the oversight system’s integrity.
“Why is it that we are conducting these audits to confirm whether or not the providers are following state guidelines through the contractor and not an association contracted with the state? And if they are announcing the review of the audit to the providers, the people in charge can just clean it all up before the review takes place – that’s not right,” said Coleman, a member of the Texas House Committee on Public Health.
“This is a wired deal,” he said. “It is planned and not by accident. The people that have been selected and how it is being operated is intentional.”
Coleman made his comments in late May, after the relevant part of the budget had already been set, with conservatives stripping away funds for women’s health as part of their anti-abortion crusade.
“It is a war in the House, and limited-income women are caught in the war,” he said.
In the Alternatives program, the rates of some violations tended to decrease between initial visits and return site monitorings for things such as fire safety (faulty smoke detectors), mingling of spiritual and education materials, and failure to display proper forms and notices.
However, subcontractors committed violations discovered during followup inspections not found during initial site visits, including billing errors and failure to secure clearances from the Department of Public Safety and Family Protective Services for mentor/counselors.
About 84 percent of the time, evaluators discovered at least one billing error. About 22 percent of the time, evaluators found that at least one mentor/counselor did not have proper public safety clearance. (An August 2008 visit to Hope Women’s Resource Clinic in Beaumont found 12 mentor/counselors without clearance.)
In total, subcontractors were found committing violations 66 percent of the time during 71 initial site visits. During 100 subsequent site monitorings, subcontractors committed violations 56 percent of the time, excluding billing errors. (With billing errors, that number jumps to 93 percent.)
Records provided by HHSC for two followup visits were missing or incomplete.
Violations reported during followup site monitorings include fire safety (15 percent of the time), possible breach of client confidentiality (12 percent), failure to display proper instructions or notices (12 percent), billing errors (84 percent) and failure to obtain proper public safety checks (22 percent). Other types of violations, including inadequate handicapped access and failure to display “No Smoking” signs, were reported about 2 percent of the time.
Typically, the corrective action pursued by TPCN consisted of having the subcontractor fix the reported violation. Billing errors were typically corrected by deducting the amount of the error from the amount of the state reimbursement to the subcontractor.
Only once did TPCN take the step of retraining subcontractor staff, in early 2010 when The Source for Women of Houston tried to secure reimbursements for serving 56 ineligible clients.
Possible breaches of client privacy included client waiting rooms that were possibly visible to the public, client forms stored in insecure or unlocked areas, and even simply “misplacing” 12 clients’ files.
The state reimburses TPCN subcontractors at a higher rate for providing mentoring/counseling than it pays, through Medicaid, nurses to provide family planning services or master’s-level mental health professionals to provide crisis counseling, as the Texas Independent has previously reported. The Medicaid rate for providing a client with a pregnancy test is $31, and the rate for a master’s-level social worker or counselor is about $41 for a 50-minute therapeutic session. Meanwhile, the state reimburses TPCN subcontractors $63 per hour for services from their mentor/counselors, who do not require any formal education or certification.
The Texas Independent reached out to multiple Republican legislators for comment on this story, but none responded.
Read the site visit reports for 2006-2010 below: