A report from Michigan\u2019s Office of the Auditor General is bringing attention to concerns within the Office of Recipient Rights.<\/p>\n
This audit is tied to a story the Investigators at Local 4 broke. An unannounced active shooter drill was held at Michigan\u2019s only state psychiatric hospital for children in December of 2022.<\/p>\n
After our reporting, a lawmaker asked for an audit of the agency who oversees Michigan\u2019s mental health hospitals — the Office of Recipient Rights. It\u2019s the agency that handles complaints, violations for the state\u2019s 5 mental health hospitals.<\/p>\n
\u201cThe audit really shed light on what, unfortunately, too many families and patients already know, which is that we deserve a better system,\u201d Michigan Sen. Michael Webber said.<\/p>\n
Here\u2019s a look at what the auditor general\u2019s report found:<\/p>\n
Nearly 30% of the complaints it looked at alleging abuse, neglect, serious injury, or death were not retrieved or acted on until 2 to 12 days after being filed. According to the state\u2019s own training materials it is supposed to react within 24 hours.<\/p>\n
More than 10% of complaints lacked a date stamp — making it impossible to determine if action was taken in a timely manner.<\/p>\n
Video surveillance at the five state hospitals was often missing or not working.<\/p>\n
\u201cThey understand that there\u2019s problems and challenges that we need to work through. So, now, it becomes, you know, what can we do from a legislative standpoint? What can we do from an oversight standpoint?,\u201d Webber said.<\/p>\n
—> Find full coverage of the Hawthorn Center investigation here.<\/a><\/p>\n Let us know if you have had an experience with the Office of Recipient Rights by emailing the Investigators at Local 4 at Local4Investigators@wdiv.com<\/a>.<\/p>\n Here\u2019s a deeper look into what the audit uncovered:<\/p>\n Problems with how violation complaints are collected<\/p>\n Audit found that the Office of Recipient Rights needs to improve how it collects alleged rights violation complaints. MDHHS agrees with the finding.<\/p>\n The audit found that the Office of Recipient Rights isn\u2019t doing a good enough job collecting violation complaints — and the agency agrees, saying it would review its process.<\/p>\n According to the audit, 70% of complaints are submitted to the Office of Recipient Rights through drop boxes in state psychiatric hospitals. But according to the agency, they typically only check those drop boxes twice a week.<\/p>\n The other 30% of complaints are sent either in-person, via email, mail, telephone, or fax. Those complaints are collected by the agency at \u201cvarying frequencies.\u201d<\/p>\n The audit reviewed 240 complaints that were received between Oct. 1, 2021 and July 31, 2024. They found that the Office of Recipient Rights \u201cdid not collect and evaluate complaints daily.\u201d <\/p>\n They also found that the \u201cORR could not always ensure it immediately initiated investigations for complaints alleging abuse, neglect, serious injury, or death involving a rights violation.\u201d<\/p>\n Almost 30% of complaints the audit looked at alleging abuse, neglect, serious injury, or death were date-stamped between 2 and 12 days after the complainant\u2019s date.<\/p>\n More than 50% of complaints alleging other violations were date-stamped between two and 53 days after the complainant\u2019s date.<\/p>\n The audit highlighted the \u201cpotential risks to recipients if there are delays in imposing necessary remedial actions to address complainants\u2019 allegations, especially those related to abuse, neglect, serious injury, or death.\u201d<\/p>\n MDHHS said it \u201cagrees with the finding and recognizes there are always opportunities for process improvements.\u201d In its response, MDHHS notes that there isn\u2019t a national mandate or standard to collect and review complaints daily — but it will \u201creview the complaint retrieval process and determine if any changes are needed to ensure timely notification of allegations of abuse and neglect.\u201d<\/p>\n Audit: ORR not responding to complaints fast enough<\/p>\n Office of Recipient Rights is required to immediately initiate an investigation for complaints involving alleged abuse, neglect, serious injury, or death.<\/p>\n In one case the Office of Recipient Rights took more than a year to complete an investigation into allegations of neglect — the allegations were proven true.<\/p>\n Investigations were not immediately started for more than 30% of abuse, neglect, serious injury, or death complaints the audit sampled.<\/p>\n The audit notes that a faster response from the ORR would help protect patients.<\/p>\n The audit found that the Office of Recipient Rights needs to improve its \u201ctimeliness\u201d for how it assesses and investigates complaints.<\/p>\n The report stated that, \u201cdoing so would help ensure potential risks of harm to recipients\u2019 well-being and\/or rights are minimized . . .\u201d<\/p>\n The audit sampled 240 complaints that were received between Oct. 1, 2021 and July 31, 2024. It noted that 26 (11%) of those complaints hadn\u2019t been date-stamped. Because they were lacking a date, the auditor couldn\u2019t tell if the ORR reacted in an appropriate time. Six of those unstamped complaints involved allegations of abuse, neglect, and\/or serious injury.<\/p>\n Ten of the 31 date-stamped complaints that alleged abuse, neglect, serious injury, or death, with a completed investigation — the dates show that the ORR did not initiate the investigation within 24 hours. The investigation ranged between 2 and 17 days after the complaint was received.<\/p>\n \u201cTimely acknowledgment is particularly important when ORR determines neither an investigation nor an intervention is warranted because it is the only ORR communication sent to complainants in these situations,\u201d the audit states.<\/p>\n For the 56 completed investigations reviewed by the auditor, 16 were overdue by a week or more. The Office of Recipient Rights took between 98 days and nearly 14 months (416 days)to complete those investigations.<\/p>\n According to the ORR, the number of complaints received, staffing errors, and employees\u2019 availability for interviews are reasons investigations might be delayed.<\/p>\n One example the audit highlighted was an incident where a patient swallowed construction hardware while under a one-to-one patient to supervisor order. The patient needed surgery to remove the hardware they had swallowed.<\/p>\n In that case, the ORR didn\u2019t initiate its investigation immediately. There were multiple status reports that either weren\u2019t completed or were completed late. It took the ORR more than a year to complete the investigation — even though the allegation was found to be true.<\/p>\n Audit finds problems with video, audio recording at state psychiatric hospitals<\/p>\n Video surveillance was available at all 5 state psychiatric hospitals, but cameras weren\u2019t always recording.<\/p>\n Audio recording was not available or was unreliable at all 5 state psychiatric hospitals.<\/p>\n All 5 state psychiatric hospitals that were open during the audit had video surveillance — but the cameras weren\u2019t always recording.<\/p>\n Three of the five state psychiatric hospitals didn\u2019t have audio recording, and the other two had unreliable audio recording.<\/p>\n For 28 of the 63 sampled investigations, video and\/or audio evidence may have helped in the investigation.<\/p>\n The state said in its preliminary response that it disagrees that monitoring the capability and availability of video surveillance systems is its responsibility.<\/p>\n The report also noted that the Office of Recipient Rights didn\u2019t have a process to regularly monitor state psychiatric hospital incident reports to check for rights violations.<\/p>\n State psychiatric hospital employees are required to report all incidents of abuse or neglect to the Office of Recipient Rights. The audit raised concerns that the Office of Recipient Rights didn\u2019t monitor that state psychiatric hospital employees are properly trained.<\/p>\n In an April 30, 2025, letter from Elizabeth Hertel to Webber, Hertel stated that \u201cthe camera systems for each hospital are robust and in working order. They are checked daily and when there is a problem, the vendor is contacted to make repairs, which is handled by the Department of Technology, Management, and Budget. It should be noted that while these cameras are stated to be in patient care areas, there are areas where cameras are not allowed where staff and patients still interact, such as patient rooms, bathrooms, and shower rooms.\u201d<\/p>\n Concerns over conflicts of interest<\/p>\n Audit states that the Office of Recipient Rights should \u201cstrengthen its monitoring of rights advisors\u2019 independence . . .\u201d that\u2019s because they are responsible for investigations and are not required to disclose potential conflicts of interest.<\/p>\n According to the audit, the Office of Recipient Rights doesn\u2019t require advisors to disclose potential conflicts of interest.<\/p>\n \u201c. . . its investigation reassignment practice for disclosed conflicts may not fully address potential advisor familiarity biases nor does it address the impact of conflicts related to the collection, date stamp, logging, evaluation, and categorization of complaints and\/or conducting interventions.\u201d<\/p>\n The MDHHS Employee Handbook does prohibit employees from taking actions that may be considered a conflict of interest with their employment.<\/p>\n In its response, MDHHS, said that the \u201cORR disagrees that rights advisors stationed on the site at the SPH (state psychiatric hospital) and completing the essential functions of their jobs are inherent conflicts of interest.\u201d<\/p>\n Improvements needed in how patients are told about their rights<\/p>\n Office of Recipient Rights needs to make sure patients know their rights and may not currently be complying with state law, audit says.<\/p>\n According to the audit, the Office of Recipient Rights needs to take steps to improve how it communicates guaranteed rights to patients.<\/p>\n This includes telling patients about services that are available to them and giving them contact information for the Office of Recipient Rights.<\/p>\n The audit found that the Office of Recipient Rights didn\u2019t always post standardized signage or the required Office of Recipient Rights information.<\/p>\n This chart breaks down the number of state psychiatric hospitals and which ones were missing required information:<\/p>\n SPHNumber of units observedMissing examples of MHC guaranteed rightsMissing ORR\u2019s addressMissing ORR\u2019s rights advisor namesMissing ORR\u2019s telephone numberKalamazoo Psychiatric Hospital65 (83%)6 (100%)5 (83%)NoneWalter Reuther Psychiatric Hospital4*1 (25%)4 (100%2 (50%)1 (25%)Caro Psychiatric Hospital4None4 (100%)4 (100%)NoneCenter for Forensic Psychiatry8None8 (100%)NoneNone<\/p>\n *According to the audit, Water Reuther Psychiatric Hospital has 5 units, but one unit was under quarantine when the auditors were on site and they weren\u2019t able to walk through that unit.<\/p>\n