Brian Sandoval Tae: Richard Whitley Governor y Director State of Nevada Department of Health and Human Services BWKS Nt ‘Community-Based Living Arrangement (CBLA) Homes Investigation Report January 26, 2018Introduction ‘On Wednesday January 17,2018, the Audit Subcommittee of the Legislative Council Bureau (LC) released a report identifying unacceptable conditions in the Community Based Ung Arrangement (CALA) homes operated by Northern Nevada Adult Mental Health Services (NNAMHS) and Southern Nevada Adult Mental Heath Services (SNAMS]. Begining Thursday, January 38%, Health Care Qualy _and Complance staf, agg and Dsailty Services Division qualty assurance ta, and staf from [NNAMIHS and SNAMHS inspected all 142 residential homes serving cen who receive state funded ‘mental health residential services _An investigative team inte Department of Health and Human Services Director's Office conducted an inguiry to compat findings ofthe LCB ad released early January 2038 with aszessment ports ‘completed by Monday, Jawary 2, 2038, The inquiry began Monday, January 22%, concluding Therséay, January 25° to enable analysis and submision ofthis report by Friday, January 25,2018, nthe time allotted, the team compared inspection results for twenty-seven (27) or 19% of Frovder homes inthe State and reviewed any aralable Inspection reports for another sevent-se (76) homes, The team azo ‘vamined documentation elated to certification processes, field notes from moxthy vst, environmental inspectors, and the qualty assurance processes within SNAMHS and NNAMIS. Information was aso attained fom agency managers and staff overseeing provcer certification and residential services “The comparative analysis of inspection reports will continue unt all homes are completed, however this investigation focused onthe rot cause ofthe break downs in process that allowed the conditions to ‘st despite the availabilty of resources and regulatory authority. To that end, the investigation team focused on answering fie primary questions: id stat conduct proper activites required for cetfiation? Did staff conducttimely inspections? id sta fail to observe problems? id staf propery report findings? ‘Are providers properly sanctioned? ‘Analyzing the sample of investigations provided suficent insight to determine oot cause Investigation Results ‘The folowing provides summary and analysis ofthe investigation findings, grouped inthe primary areas of iwestigation. Tre investigation identified several falure points tha ocurred throughout the proces. Some of those filre points diflered by region, bu the overarching theme demonstrates the Inability of program staffto propery inspect and ceguat the providers that operate the homes. Furthermore, there were significant areas of concern regarding communication fllow-up, and oversight ver the program. Page tof‘Certification Assembly ll 4 was signed bythe Governor June 1, 2017 and gave the Division of Public and Beraviral Health (OPBH) regulatory authority to cert and inspect all homes clasied ata CBLA. The dviion completed the regulation to implement the lw and those regulations were adopted by the Board of Health on July 1, 2017. This certifications atthe provider lve, not the home evel. Documentation related to certification s confusing a there have been several attempts to certify providers. The fles ‘kept bythe program sometimes had certification fom prior attempts which made documentation review confusing. However, based on what documentation was avaliable and on material provied by rogram managers, onl porion ofthe currently operating homes are certified under the new Standards. WNAMHS has not empleted certifying ny ofthe eleven (1) providers they tile. SNANHS has certified fourter (18) providers ofthe eighteen (28) providers they uli. There are currently 2 total of twenty-nine (28) providers Of those who were certifi, there was evidence that staff di conduct the required atvitis. However, the documents are nat maintane electronically and are cfficut to acess and review. Despite having the certification equlrement in place sac uly 2017, hal ofthe providers remain uncertified and certifation atthe provider level does not appear to have any impact on the conition and operation of the individual homes. Timely Inspections ‘This was dfiult area for revew. Environmental eviews and inspections were supposed tobe incorporated into the monthlyhome vst. However, theres no evidence to support such inspections ‘consistently occurred. it appeut that during 2016-2017 there was atime where monthly inspections took place inthe North. However, these ceased or were curtailed greatly during the creation and Implementation ofthe cerfietion standards. The investigation team found inadequate and incomplete environmental inseetions inthe South There is evidence to suppor tiely annual inspections with anyone (1) exception within the sample analyzed. However, thece waslitle evidence of tine inspections to followup an coreetive action plans. From the avaiable documentation, it appears that 30-60 days after the corrective action pan is received the provider reports 1o the state completion of any outstanding issues. However, based on documentation it might not be unt the next anna inspection that a caseworker observes and documents whether the sues were resolved Staff Observations and Reporting, Staff observations and report af condition inthe homes varied signiianty by region. NNAMS Inspection reports often detailed issues inthe homes. Infact, allbut one of the NNAMHS homes had some form of corrective atin plan. However, staf reported sigficant challenges in enfrcingthe plans and ensuring the corrective actions were taken, “SHAMS inspection reports often only detailed compliance or areas of concern with medication ‘management and basic heath nd safety such as fie extinguisher inspection, but often failed tonote unsanitary and public heath hazard isues. Very few residences had corrective action plans, and there ‘was no documentation regardng notices for deficiency in compliance. It appeats from the inspection reports that nurses do the mesication evaluation not caseworkers. That could account forthe Consistent focus on medication management with ver litle focus onthe environmental review. rage 2088Numerous reports included some recommendations, but then noted that nofollow up was required. “There was a consistent pattern of under-reprtinglsues and many ofthe reports appeared tobe nearly identical to others completed “The handuriten reports were lfc o read anc often not signed by the reviewer, Adatonally, he ‘forms contained personally identifiable information or nats about the health ofthe consumers nthe homes. Staff noted that they dnt enter rooms and felt uncomfortable looking in cupboards or at personal items as they fe that it was an invasion of the individual's privacy. The review forms were aften incomplete and did not have any way to Inleatesuperusory revew. i ikely, and there was evidence observed curing inspections, that clinical stlf.do not have the skis to look fr and identify envionment concerns Provider Sanctions “The regulations developed by the program prove for provider sanctions inthe form of withdrawing or suspending certification and withholding payment. NNAMHS had closed one ofthe homes included in ‘the LCB aut (home 1 plus tree additional homes (two providers). The rst provider was dosed September 15,2017. The second provider willbe closed as of January 31,2038, The lst af the residents from these homes wil berelocated bythe end of next week asthe closure ls fnalze, Three of the twenty seven provider les reviewed demonstrated use of corrective action plans and fellow up indicating lesues had been resolved. Results nthe North forthe Januar inspections were that 28 of31 homes inspected required follow up. nthe South, 84 ofthe 121 homes inspected required follow vp. It doesnot appear that NNAMHS and SNAMHS have ful integrated sanctions ito practice a ‘theres a grave concer egarding where these cents wl ve residential serves homes close. Communication Serious breakdowns in communication were evident throughout this investigation. In the North, areas ‘of concern with providers were communicates tothe Administrator well before the UCB aud wos ‘completed. Action was taken against some provers and homes were lsed, but nether concerns nor ‘actions taken were communicated tothe Directors Office and there is no further dacumentation that ‘the Norther attempts to enforce compliance with corrective action were supported even after identification and documentation by staff and managers Inthe South, procedures such as manual tallying up the aeas of noncompliance were put nt place by ‘the manager to ensure supervisors would read the inspection reports, bu that doesnot seem to have ‘encouraged action. Adtlonally, as there was significant amount of under-teporting of sues in the South, that procedure would not have resulted indenting that underreporting although the slmilarityin report overtime should have been aticeable. Abo, the monthly tly didnot factor in scope and severity ofthe area of non-compliance so was only of lnited usefulness in monitoring the Inspections Last, eviews of reporting between the DWvislon Administrator andthe Director through monthly and (quarterly reporting indicates that very litle mention was made ofthe audit or of concerns identified by program manages. Inthe followup t the aut Dvson leadership stated that they were contesting the results and tok no actions to immediately resolve the issues despite assurances tothe Director's Office that they were ensuring the safety of the individual Page 3 ofConclusion It apparent the function of regulating these homes and proers ie not appropriataly places within cline serves, ‘Further investigation ito individual staff actions and esponibtes wl be completed bythe Department's himan resources Investigation team to determine appropriate corrective action. ‘©The mult-dsciplinary team comprised of Health Care Quality and Compliance staff and the Director's Ofc staff wil remain in charge ofthe vewight proces. “+ Corrective ation plans for individual homes will be monitored at the Department level unt the systemic changes ae Implemented and the regulation of thehomesis under appropriate +The Department has begun the process of embeddingthe regulatory function within the Bureau cof Health Care Quality and Compliance Page aot