Brian Sandoval Richard Whitley Governor Director State of Nevada Department of Health and Human Services NU, oN DHHS Ne ‘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 (LCB) released a report identifying unacceptable conditions in the Community Based Living Arrangement (CBLA) homes operated by Northern Nevada Adult Mental Health Services (NNAMHS) and Southern Nevada Adult Mental Health Services (SNAMHS). Beginning Thursday, January 18%, Health Care Quality and Compliance staff, Aging and Disability Services Division quality assurance staff, and staff from NNAMHS and SNAMHS inspected all 142 residential homes serving clients who receive state funded ‘mental health residential services. ‘An investigative team in the Department of Health and Human Services Director's Office conducted an inquiry to compare findings of the LCB audit released early January 2018 with assessment reports completed by Monday, January 22, 2018. The inquiry began Monday, January 22", concluding Thursday, January 25 to enable analysis and submission of this report by Friday, January 25, 2018, In the time allotted, the team compared inspection results for twenty-seven (27) or 19% of provider homes in the state and reviewed any available inspection reports for another seventy-six (76) homes. The team also examined documentation related to certification processes, field notes from monthly visits, environmental inspections, and the quality assurance processes within SNAMHS and NNAMHS. Information was alse attained from agency managers and staff overseeing provider certification and residential services. The comparative analysis of inspection reports will continue until all homes are completed, however this, investigation focused on the root cause of the break downs in process that allowed the conditions to exist despite the avallability of resources and regulatory authority. To that end, the investigation team focused on answering five primary questions: Did staff conduct proper activities required for certification? Did staff conduct timely inspections? Did staff fail to observe problems? Did staff properly report findings? ‘Are providers properly sanctioned? Analyzing the sample of investigations provided sufficient insight to determine root cause. Investigation Results The following provides @ summary and analysis of the investigation findings, grouped in the primary areas of investigation. The investigation identified several failure points that occurred throughout the process. Some of those failure points differed by region, but the overarching theme demonstrates the inability of program staff to properly inspect and regulate the providers that operate the homes. Furthermore, there were significant areas of concern regarding communication, follow-up, and oversight over the program. Page 1of 4Certification Assembly Bill 46 was signed by the Governor June 1, 2017 and gave the Division of Public and Behaviorat Health (OPBH) regulatory authority to certify and inspect all homes classified as a CBLA. The division completed the regulations to implement the law and those regulations were adopted by the Board of Health on July 1, 2027. This certification is at the provider level, not the home level. Documentation related to certification is confusing as there have been several attempts to certify providers. The files kept by the program sometimes had certifications from prior attempts which made documentation review confusing. However, based on what documentation was available and on material provided by program managers, oniya portion of the currently operating homes are certified under the new standards. NNAMIHS has not completed certifying any of the eleven (11) providers they utilize. SNAMHS has certified fourteen (14) providers of the eighteen (18) providers they utilize. There are currently a total of twenty-nine (29) providers Of those who were cerified, there was evidence that staff did conduct the required activities. However, the documents are not maintained electronically and are difficult to access and review. Despite having the certification requirement in place since July 2017, half of the providers remain uncertified and certification at the provider level does not appear to have any impact on the condition and operation of the individual homes. Timely Inspections ‘This was a difficult area for review. Environmental reviews and inspections were supposed to be incorporated into the monthly home visits. However, there is no evidence to support such inspections consistently occurred. It appears that during 2016-2017 there was a time where monthly inspections took place in the North. However, these ceased or were curtailed greatly during the creation and implementation of the certification standards. The investigation team found inadequate and incomplete environmental inspections in the South. ‘There is evidence to support timely annual inspections with only one (1) exception within the sample analyzed. However, there was little evidence of timely inspections to follow-up on corrective action plans. From the available documentation, it appears that 30-60 days after the corrective action plan is received the provider reports to the state completion of any outstanding issues. However, based on documentation it might not be until the next annual inspection that a caseworker observes and documents whether the issues were resolved. Staff Observations and Reporting Staff observations and report of conditions in the homes varied significantly by region. NNAMHS inspection reports often detailed issues in the homes. In fact, all but one of the NNAMHS homes had some form of corrective action plan. However, staff reported significant challenges in enforcing the plans and ensuring the corrective actions were taken. SNAMHS inspection reports often only detailed compliance or areas of concern with medication ‘management and basic health and safety such as fire extinguisher inspection, but often failed to note unsanitary and public health hazard issues. Very few residences had corrective action plans, and there was no documentation regarding notices for deficiency in compliance. It appears from the inspection, reports that nurses do the medication evaluation, not caseworkers. That could account for the consistent focus on medication management with very little focus on the environmental review. Page 2 of 4