The Department of Health and Human Services launched an internal investigation Thursday into how squalid conditions at community homes for Nevada’s mentally ill persisted for almost two years after top department officials were made aware of the problem and implemented policy changes to fix it.

The investigation will seek to identify specific failures within the department that allowed Nevada’s mentally ill to live in houses with feces smeared on floors, flies clinging to door frames and mold creeping up baseboards under the guise of a home-based care model intended to provide patients with an independent-living experience while still receiving the help they need. The announcement comes just a day after a panel of lawmakers was presented with detailed descriptions by legislative auditors and pictures of filthy and unsafe living conditions in 37 community-based living arrangement homes.

HHS Director Richard Whitley said he has more questions than answers in a situation he thought his department addressed nearly two years ago when news reports about similar conditions in the homes surfaced. But he took full responsibility for what happened and for figuring out why the deplorable conditions in the homes were never addressed when department employees were conducting monthly inspections.

“Why is this happening? We have staff going out there, so where is the failure,” Whitley said. “I take the responsibility for this. It falls on my agency. The governor has relied on me.”

Department staff inspected 12 of the 37 homes audited within five days of the legislative auditors’ inspection but didn’t document most of the problems the auditors found, according to the 69-page audit. The auditors identified 140 items that did not comply with the department’s inspection checklist, where the staff only found 28 problems.

“If you read the audit, you see that they were in facilities that we were in days before, so how did they — really, you just need to look at the pictures to see — how did they see something that we missed or didn’t report?” Whitley said.

The first step in the investigation is to re-inspect each of the 105 so-called community-based living arrangement homes in Nevada, a process that started Thursday and will likely wrap up by the end of the weekend. The department has dispatched inspectors from the Bureau of Health Care Quality and Compliance, a separate agency responsible for licensing all medical and other health facilities in Nevada, to accompany the case managers typically responsible for conducting the monthly checks.

“Part of the investigation, too, is we want other eyes. We don’t want to send out the staff we’ve been sending out,” said Deputy Director Julie Kotchevar, who has been tasked by Whitley with overseeing the department’s internal investigation. “We wanted extra people there, but particularly trained investigators.”

The department doesn’t know whether the case managers just aren’t reporting the problems they’re observing during their monthly inspections, which were implemented in the wake of a Reno Gazette-Journal story in early 2016 detailing filthy conditions in the homes, or don’t recognize what they’re seeing as a problem. It’s also possible that case managers are reporting the serious problems they’re observing and those concerns just aren’t being elevated up the chain of command.

“What has me worried is these are case managers going out and looking. These are folks that are helping folks navigate the service system,” Whitley said. “So that actually has me worried and why the drive to actually get at where the problem is. It certainly wouldn’t solve the problem if they are reporting it and in the management hierarchy it’s not getting reported up and action taken.”

One possible long-term change Whitley said he could consider, depending on the outcome of the investigation, is to take the environmental inspection responsibility away from the case managers and turn it over to the Bureau of Health Care Quality and Compliance permanently. Doing so would separate the tasks of identifying a problem with a patient’s living situation with the responsibility of finding the patient a new home, which could discourage case managers from reporting problems if they’re responsible for also finding the solution.

Whitley said that he spoke on Wednesday with the regional managers in the Northern Nevada Adult Mental Health Services and the Southern Nevada Adult Mental Health Services, agencies within the department, who assured him that all of the patients in the community homes are safe. But he and Kotchevar are operating under a “trust but verify” mentality right now until they can figure out where the breakdown in the process is happening.

Whitley said if the case managers and health-care inspectors visiting the homes over the next couple of days determine a client is in immediate jeopardy, they are directed to not leave until the problem is remedied. That includes everything from ensuring that patients have adequate food to checking that all smoke detectors are working.

But Whitley and Kotchevar are perplexed because these are all tools that have been and continue to be available to case managers during their monthly inspections.

“Without sounding shrill, we have all the tools. I mean, that was one thing that the governor back in 2016 when we had the original housing issue with the complaint, the governor asked what we needed to address the problem. He put his trust in me to fix it,” Whitley said. “Now to see that we’ve been out there and didn’t act on seeing what the auditors saw, I have to know why that is and fix it now.”

After the re-inspection process is complete, Kotchevar will compare the monthly inspection reports with the results from the re-inspection to identify any discrepancies. From there, she can determine whether fault lies with individual case managers themselves in not recognizing or reporting problems, or whether they are identifying the problems and the failure lies somewhere further up in the chain of command.

The department will present an action plan to the governor on Monday laying out the next steps for the investigation. Once the investigation is complete, Whitley said he can decide what action is appropriate to take, including policy changes within the department, corrective action plans or terminations of contracts for providers and personnel changes within the department.

Whitley said that he has monthly meetings with all the administrators in his department — which would include Amy Roukie, administrator of the Division of Public and Behavioral Health, which houses the agencies that run the community-based living arrangement program  — where they share complaints and look for any themes to identify systemic issues. But he says that he did not receive any complaints or any reports from Roukie, who said at the Wednesday meeting that the audit’s findings were “in many cases as shocking to us as they were to the committee.”

Kotchevar said the investigation will also look at what action division staff have taken since they received a draft report of the audit back in October. Though she said division staff initially disputed some of the findings contained in the draft report of the audit — some of which were ultimately removed — they should have been working on fixes to the parts they didn’t dispute since then.

“One of the things we were asking Amy and her staff yesterday was, ‘You didn’t dispute all of the findings. You told us you were working on it. You need to start sending us that information because you told us you were working on it,’” Kotchevar said.

At the Wednesday meeting, Roukie also placed some of the blame on the fact that some of the homes, including seven of the 37 homes included in the audit, are operated by an outside organization and therefore Southern Nevada Adult Mental Health Services wasn’t allowed to certify them. When asked by GOP Sen. Ben Kieckhefer, R-Reno, if she could assure lawmakers that no one is living in these conditions anymore, Roukie said she couldn’t “100 percent” guarantee that those conditions don’t exist.

“And those provider homes that we don’t certify, that’s where our issue is and that’s where we’re going to ensure they become certified,” Roukie said.

But a new law passed in 2017, which kicked into effect on July 1, gave the division authority to certify those homes. That’s another thing Kotchevar will look at in her investigation — whether the division is certifying the homes, and if not, why not.

Still, as Assemblywoman Teresa Benitez-Thompson, D-Reno, pointed out on Wednesday, every single home out of the 37 audited, certified or not, had multiple issues, ranging from unsanitary conditions to personal and safety hazards.

“I think, actually, it was reported out in the hearing by Amy that some of these providers weren’t certified by us and the authority didn’t come until July, but that didn’t seem to matter though,” Whitley said. “Yes, true, that’s a problem with those that previously we didn’t have authority for, it might have been worse, but that doesn’t account for the ones we were going out to and seeing and identifying all these problems. I suspect that will be part of my personnel action as well.”

For Whitley, the failure of his department to oversee the community homes is a blow to the improvements to mental health that the department and the governor have prioritized over the last several years, and he said he worries it will overshadow the good they have tried to do. For instance, in 2012, Gov. Brian Sandoval became the first Republican governor to opt into Medicaid expansion, in large part to leverage federal dollars to move mentally ill patients out of state-run institutions and into private care.

“This is a horrible problem, but it didn’t need to be. It overshadows the improvement that has been been,” Whitley said. “I’m passionately committed because of the concern for our vulnerable population and because the governor has put so much trust in me to deliver this.”