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Report: ADHS failing to investigate complaints at nursing homes

“It shouldn’t happen,” Don Herrington, interim ADHS Director said. “Family members should know what’s going on.”

ARIZONA, USA — Arizona’s Department of Health Services has been improperly investigating complaints, if at all, for years according to a new report out by Arizona’s Office of the Auditor General.

In a 30-month follow-up report on the Arizona Department of Health Services, the Auditor General found:

  • The Department inappropriately closed most High-Priority complaints without a required on-site investigation, including complaints of abuse or neglect. 
  • ADHS failed to initiate on-site investigations for nearly three-quarters of its High Priority complaints
  • The Department “inappropriately” changed complaint statuses to extend required response times for complaints.  

The follow-up report was based on data collected from ADHS from July 1, 2019, to April 21, 2021.

According to the report, a High-Priority complaint could be allegations of abuse or neglect and constitutes something that “impairs a resident’s mental, physical, and/or psychosocial status, or hazards to health and safety that may exist and are likely to cause a significant problem in care and treatment, but that does not rise to the level of an immediate and serious threat.” ADHS is supposed to do an on-site inspection within 10 days if a complaint is deemed a high priority.

Interim ADHS Director Don Herrington said he did not anticipate a follow-up report with accusations like this.

“I can understand on the surface that that’s very disturbing to people,” Herrington said over a Zoom call Wednesday. “I think from our perspective we also want to make sure that it’s accurate.”

Findings: Complaints closed without investigation; downgraded in priority

The audit determined that ADHS didn’t investigate according to Centers for Medicare and Medicaid Services (CMS) investigation requirements and that “investigation failures” put residents in long-term care facilities like nursing homes at risk.

For example, the audit details that in October 2020, ADHS received a complaint regarding the care of a nonverbal, dependent resident at a long-term care facility.  ADHS labeled this complaint as sexual abuse and assigned it as High-Priority, but did not send anyone to act immediately as CMS requirements state. The audit claims the department failed to conduct the required on-site inspection and couldn’t substantiate whether sexual abuse occurred. The complaint was ultimately closed eight months later without the Department taking any action against the staff because it didn’t have information from its own investigation.

In another example, the report claims that in January 2020 ADHS received a complaint from the spouse of a man in an unnamed long-term care facility who had unexplained bruising and a sore on his tailbone from being left soiled for extended periods of time.  After the Department received the complaint, it listed seven different allegations to investigate and assigned the complaint as High-Priority. The audit found that the Department did not act on the complaint until April 2020 when it was downgraded and ultimately closed without any investigation.

Another example details that the Department received an abuse complaint in December 2018. That complaint was labeled as High-Priority, but the state did not investigate within 10 days. The audit claims one of the resident’s family members called the Department eight times for updates before an investigation was started 14 months later in February 2020.

The audit also accuses ADHS of improperly reassigning a majority of its open High-Priority cases to Medium- or Low-level priorities, which don’t need to be investigated as quickly.

Other concerns detailed in the audit include Department staff not knowing CMS requirements; ADHS “inappropriately” closing backlogged complaints, and the public not having confidence in ADHS. 

Arizona’s Department of Health Services responds

Interim ADHS Director Don Herrington said he and his staff learned about the report earlier in the month and asked the Office of the Auditor General to provide more details so his department can investigate internally. He said he didn’t know if any of the allegations were true but that he’d be looking into it.

“If we did do something wrong, then we can take measures to correct it,” he said.

Herrington took over as interim director last year after Dr. Cara Christ left the role in August 2021.

“I think the fact is we’re a unit here regardless of who is sitting in what chair,” Herrington said. “And we’ll own up to things we should own up to and if there’s a dispute on our part, we’ll dispute that, as well.”

As for allegations that complaints, including abuse, aren’t being investigated on time or at all.

“It shouldn’t happen,” Herrington said. “Family members should know what’s going on.”

The follow-up report stemmed from a 2019 state audit that found the Department “failed to investigate or timely investigate some long-term care facility complaints.” The follow-up report found ADHS did not implement any changes recommended for improvement detailed in the 2019 audit.

The new report detailed “a lack of staff or the COVID-10 pandemic do not explain the problems we identified in this follow-up report.”

Herrington disagreed, saying they operated with reduced staffing and had limits on inspections due to COVID-19 concerns and policies. He also said the priority was shifted to ensure care facilities had COVID-19 control policies in place.

“Most of the folks that do this type of work are nurses and nurses were in very high demand for all kinds of medical facilities and particularly medical facilities that could pay a lot more than what we paid,” Herrington stated. “We a lot of turn over.”

He said staffing is still a concern more than two years after the pandemic began.  As of right now, he said they are down 15 surveyors who handle long-term care facility complaints. He said he’s been working with the Arizona Department of Administration to try and raise pay to recruit and retain people for these roles.


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