An internal investigation by the Department of Health and Human Services sent to the governor on Friday concluded that “serious breakdowns in communication” between department staff allowed filthy and unsafe conditions to persist at community homes for the mentally ill and that the responsible administrator made little mention of the problems to the department’s top official.

The investigation found there was no evidence that the so-called community-based living arrangement homes, where a caretaker provides supervision and treatment to a small group of mentally ill clients, were being inspected on a monthly basis, as was supposed to be the case after a change in department policy when the unsafe conditions first came to light in a Reno Gazette-Journal story in February 2016. Even when the inspections were completed, staff were either unable to enforce the required corrective action or failed to note basic health and safety problems in the homes in the first place, the report concluded.

Department Director Richard Whitley launched the internal investigation the day after a panel of lawmakers was presented with detailed descriptions by legislative auditors and pictures of filthy and unsafe living conditions in 37 of the homes. Auditors found unsanitary conditions in the home — feces smeared on the floor, flies clinging to door frames and mold on baseboards — as well as unsafe conditions, such as missing smoke detectors, broken glass and open flames.

For homes in Southern Nevada, the inspection reports typically only detailed issues with patients' medication management and basic health and safety problems, such as the inspection of fire extinguishers, failing to note sanitary and public health issues. The investigation noted that it appears that nurses are responsible for the medication evaluation, not caseworkers, which could account for the focus on medication management in the inspection reports with not much focus on the environmental review.

The report also found that few homes in Southern Nevada had corrective action plans, and there was no documentation for notices for deficiency in compliance. And although “numerous” reports included some recommendations, they also noted that no follow up was required.

“There was a consistent pattern of under-reporting issues and many of the reports appeared to be nearly identical to others completed,” the report said.

The investigation found far better inspection reports in Northern Nevada, with all but one home having some sort of corrective action plan. However, staff had difficulty enforcing the corrective action plans, the investigation concluded.

More broadly, the investigative report found that neither staff in the north nor the south have integrated sanctions for providers who fail to implement corrective action plans in the homes into their practices due to a “grave concern” over where the clients will live should they be required to close the homes.

A reinspection of the homes in the wake of the audit’s release in January revealed that 28 of 31 homes in the north and 84 of 111 homes in the south require follow up. One home contained in the audit has already been closed, in addition to three other homes, all in Northern Nevada.

It is also unclear how often the monthly checks occurred. Although environmental reviews were supposed to be incorporated into monthly home visits after the March 2016 policy change, the investigation report found that there were “inadequate and incomplete” inspections in the south, and that although inspections appeared to take place for a time between 2016 and 2017 in the north, they “ceased or were curtailed” greatly while staff was working on creating and implementing certain certification standards for the homes.

A new law passed by the Legislature in 2017 gave the Division of Public and Behavioral Health the authority to certify and inspect all of the community-based living arrangement homes, which they were previously unable to do. However, none of the 11 providers in Northern Nevada have been certified since the law went into effect in July, and four of the 18 providers in Southern Nevada have yet to be certified.

But the report also found “serious breakdowns in communication” within the department. It noted that concerns with providers in the North were communicated to former Division of Public and Behavioral Health Administrator Amy Roukie, who resigned on Jan. 19 after providing false testimony to the lawmakers on the issue, “well before” the legislative audit was completed.

“Action was taken against some providers and homes were closed, but neither concerns nor actions taken were communicated to the Director’s Office and there is no further documentation that Northern attempts to enforce compliance with corrective action were supported even after identification and documentation by staff and managers,” the report said.

Additionally, the investigation found that Roukie made “very little mention” of the audit or concerns identified in her reports to department Director Whitley. When the draft report of the audit was submitted in October, the division told the director’s office that it was contesting the results.

The division “took no actions to immediately resolve the issues despite assurances to the Director’s Office that they were ensuring the safety of the individuals,” the report said.

The department has already begun the process of turning the environmental inspection of the homes over to the Bureau of Health Care Quality and Compliance, responsible for inspecting medical facilities, and corrective action plans will be monitored at the department level until “systemic changes are implemented,” the report said. Further investigation into individual staff actions will be completed by the department’s human resources team.

  Community-Based Living Arrangement Homes Investigation Report - January 26, 2018 by Megan Messerly on Scribd