As the state works to remedy the deplorable conditions in community homes for the mentally ill identified in a legislative audit last month, lawmakers and state officials are grappling with the bigger question of how to better oversee and tailor care to meet patients’ needs.

Officials with the state Department of Health and Human Services presented to a legislative committee on Tuesday their progress in remedying filthy and unsafe conditions in the so-called community based living arrangement homes, including the closure of nearly a dozen homes and the issuance of more than 100 corrective action plans over the last month. But they also identified the need for longer-term changes in the way the state provides care to those struggling with mental health issues, such as active and intensive treatment or skill acquisition and job training.

Since the presentation of the legislative audit in January, one home was closed and two more have voluntarily closed in Northern Nevada, and four provider homes were closed in Southern Nevada. Three more homes in Northern Nevada were closed between August and December as Northern Nevada Adult Mental Health Services began going through the process of certifying the homes, as authorized by a new law that went into effect in July.

Additionally, 28 locations in Northern Nevada and 59 locations in Southern Nevada were issued 10-day corrective action plans. The Northern Nevada corrections have been confirmed, while the state is still reviewing documentation demonstrating completion of the corrections for the Southern Nevada Homes.

Twenty-five additional homes were issued 30-day corrective action plans in Southern Nevada, which will be verified as complete by Monday. One Southern Nevada provider, Mojave Mental Health, was issued a 30-day termination notice and is in the process of relocating the patients served by that program.

The closures and corrective action plans come in the wake of a legislative audit that found the state ignored squalid living conditions for mentally ill patients living in the community homes for more than two years after the conditions first came to light in a Reno Gazette-Journal story. The 69-page report detailed filthy and unsafe conditions, including human feces smeared on a floor in a bathroom, mold and mildew creeping up baseboards and broken or missing smoke detectors.

In days immediately after the presentation of the audit, the Department of Health and Human Services re-inspected the 142 community-based living arrangement homes, sending the regular case workers typically responsible for the site visits along with inspectors with the Bureau of Health Care Quality and Compliance (HCQC), responsible for inspecting medical facilities. During those inspections, inspectors confirmed the welfare and safety of every client and issued the 10- and 30-day corrective action plans.

After the initial inspections, the department sent seven- and 30-day action plans to Gov. Brian Sandoval, laying out both short- and long-term fixes to ensure the homes are operating as they should be. They also sent the governor the results of their internal investigation, which found that “serious breakdowns in communication” between department staff allowed the filthy and unsafe conditions in the homes to persist and that the responsible administrator, Amy Roukie, made little mention of the problems to department head Richard Whitley. (Roukie resigned after it was discovered she was untruthful to a legislative committee when the audit was presented.)

But beyond the immediate steps needed to fix glaring issues with the homes, department officials are now looking to bigger picture changes, such as hiring a community integration manager who will be responsible for ensuring that patients in the homes are receiving help with acquiring skills and gaining independence.

“One of the things besides the condition of the homes that was most upsetting to me is that people were there all day and weren’t doing anything related to active treatment or intensive treatment or skill acquisition or job training or supportive employment,” said Julie Kotchevar, interim administrator of the Division of Public and Behavioral Health. “They were largely there during the day not getting services.”

They’re also looking at how to better educate and train case workers to report back any problems they’re observing in the homes and how to utilize different housing options to improve quality of life and health for patients. The department will also move toward using level of care assessments to identify individualized patient needs, instead of lumping everyone together who isn’t a risk of harming themselves or others in the community homes as if they need the same level of care.

Sen. Julia Ratti, D-Sparks, also suggested a comparison between the standards for community-based living arrangement homes and those for group homes that are regulated as medical facilities under Nevada law, which are inspected by HCQC and subject to more stringent requirements. The department is in the process of recruiting HCQC inspectors to oversee the community homes.

Kotchevar said that some of the nicest community-based living arrangement homes she visited were homes that had a mixed patient population and were licensed as medical facilities and already regulated by HCQC. She said the homes were operated “really well” and didn’t have the same deficiencies that many of the other homes did.

“Clearly the big difference here is HCQC is regulating these homes to a higher level,” Kotchevar said.

Lobbyist Helen Foley, on behalf of the Nevada Assisted Living Association, detailed to the committee the strict requirements for medical facilities: specific training and continuing education requirements for medication management, square footage requirements, minimum and maximum temperatures, laundry and linen services and even how much fresh and canned food has to be on hand. She said it is “crazy” that the community homes aren’t subject to the same requirements.

“Our thought is if there are any people placed in a situation where they pay for their services and it’s between two and 10 individuals in a home … that all of them have to follow the exact same (medical facility) guidelines,” Foley said. “Wrap them into (the medical facilities statue) so they have adequate care and services.”