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Community homes for the mentally ill: A failure of policy implementation

In 25 plus year of writing about state and local government, we are often stunned by how much time and attention goes to creating policies and processes and how little time and attention goes to policy implementation.

"Unsanitary and unsafe conditions."

There’s no better evidence of the chasm between policy vision and policy implementation than the photos on this page, which were pulled from a January legislative audit of community-based living arrangements for the mentally ill in Nevada.

We’re not talking about a few bad actors here. The performance audit of the Division of Public and Behavioral Health looked at 37 provider homes. “We observed serious, deficient conditions in all 37 homes inspected,” the audit reported. “Although the Division developed policies and procedures to inspect provider homes, staff implementation of procedures is inadequate.”

This isn’t the first time that Nevada officials have learned about community living problems for the mentally ill. Newspapers reports about deplorable conditions in the last few years resulted in a slew of new policies, including standards established in 2014 for certifying providers, and clear requirements to inspect homes regularly.

"Poor medication management."

Two Nevada agencies, which are part of the behavioral health division, oversee providers. One operates in the southern part of the state. The other in the north. The policy for Southern Nevada Adult Mental Health Services, effective April 2016, says its home placements for the mentally ill provide “independent living with the security of monitoring, continued support and behavioral skills training in a scattered site community Center.” A similar policy exists in the north. More legislation was passed in 2017 providing for certification and regulation of community-based homes.

Currently, providers get an average of $1450 a month from the state for each resident and may also receive funding from the federal government via Social Security Administration disability checks. An average of four residents are housed in each home. The audit alludes to the temptation that some providers may have to skimp on services, care and basic home maintenance. “Providers operate a business that inherently is driven by a profit motive. In the absence of adequate inspection and certification activities, providers may limit their level of care to maximize profits at the detriment of client services.”

"Rodent and insect infestations."

On Friday, The Nevada Independent reported that the Nevada Department of Health and Human Services had immediately responded to the situation and would re-inspect 105 “community-based living arrangement” homes. The department’s director, Richard Whitley,  was also clearly stunned by the audit and the photos that accompanied it, and baffled that agency inspectors had missed the problems witnessed by auditors.  “If you read the audit, you see that they were in facilities that we were in days before, so . . . how did they see something that we missed or didn’t report?” Whitley told reporter Megan Messerly. “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.”


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