Citing "deplorable conditions" that could have resulted in serious harm or death, the state Department of Human Services is revoking licenses of three private facilities that primarily house mentally ill residents.
The revocations are based on inspections and photographs taken over the past two months that detail uncovered electrical outlets, commodes covered with feces, unheated rooms, roaches, smoke detectors dangling from the ceilings and improperly dispensed medications.
State regulators had ignored many problems until a private advocacy group complained. A Disability Rights Center employee took pictures and exposed conditions at one of the facilities. That complaint led Human Services Department officials to overhaul their inspection procedures and order new inspections at other facilities with the same owners.
"We have real concerns about whether the personal care we paid for was provided," said Ray Hanley, director of the department's Medical Services Division. "The conditions were deplorable. There's no excuse for the filth, and it was apparent that it didn't happen overnight."
In documents turned over to the Arkansas Democrat-Gazette under the state Freedom of Information Act, the agency blocked out the names of the owners. It cited a state law its attorneys said shields all inspections of residential care facilities.
Residential care facilities provide a home for residents who are elderly, mentally ill or mentally retarded but are not so impaired as to require a nursing home. In the past, the facilities were referred to as boarding homes or room-and-boards.
Despite the state's position the Democrat-Gazette has learned that Avanell Looney of Sparkman and her son, Joe Alexander of Camden, co-own three facilities and that she is sole owner of a fourth. Licenses at all four facilities are in jeopardy.
State records show that Alexander and Looney own Alternatives Plus in DeWitt, which is licensed for 60 residents; Camden Family Inn in Camden, licensed for 40; and De Queen Residential Care Facility in De Queen, licensed for 29. Looney is the sole owner of Sparkman Care Center in Sparkman, which is licensed for 53 residents.
Of the four facilities, three are losing their licenses March 19, but it could not be determined which three. Officials have set a Friday deadline for the fourth to comply with state regulations.
The owners can appeal the license revocations to the Long Term Care Review Board.
Besides the increased attention from the Human Services Department, the state attorney general's office seized records from the facilities at DeWitt, De Queen and Sparkman last week, according to Bill Gaddy, director of the office's Medicaid Fraud Control Unit. The office could make a criminal referral or file a civil action to recoup funds or impose penalties.
The Human Services Department also has:
- Imposed penalties totaling $14,500 against the four facilities.
- Demanded repayment of $220,000 in state and federal funds for personal care services the agency says weren't provided.
- Stopped payment of Medicaid personal care funds to these facilities.
- Asked its Adult Protective Services Unit to investigate for possible referrals to prosecutors or the state attorney general.
- Sent inspectors across the state for surprise inspections to 20 other residential care facilities.
- Started administrative reviews on employees in the department's Office of Long Term Care for failure to aggressively enforce regulations.
Alexander, who has represented the facilities in dealings with the state, did not return repeated telephone messages left at the four facilities. However, Dr. Ray Nelson, former commissioner of the state Developmental Disabilities Services Division from 1981-84, said he has been hired by Alexander and Looney to bring the four facilities into compliance.
Nelson said the owners will appeal the revocation notices and renovations are under way at all four facilities.
"The plan for some time has been to renovate," he said. "They are putting lots of money into the facilities."
Arkansas has 138 private residential care facilities licensed to care for nearly 5,000 people. The state began regulating them in 1980. The state Legislature toughened the standards in 1985 after the Arkansas Democrat exposed abuses and lack of inspections.
The state has eight investigators who visit the 138 facilities twice a year.
Arkansas' residential care facilities vary widely in price and quality. About two-thirds deal exclusively with the elderly.
For disabled residents with little or no income, monthly fees often come from a $500 Social Security check. In those cases, the resident signs over the check to the facility and is given back about $30 for personal items.
In 1991, the Human Services Department decided to reimburse residential care facilities for personal care such as helping a resident with bathing, grooming, eating and taking medications. The agency was the first in the country to use federal Medicaid money and state matching funds in this way.
Facilities receive $12.35 an hour for up to 64 hours a month -- up to $790.40 per resident -- to perform personal care for those who qualify for this Medicaid service.
The four facilities cited by the department received $906,937 in Medicaid funds in the state's fiscal 1998, which ended June 30, for personal care services, in addition to the monthly payment by the residents.
The Disability Rights Center, a private organization formerly called Advocacy Services, uncovered the problems at Alternatives Plus in DeWitt and alerted the Office of Long Term Care in late December.
"Our advocate, Daniece Gibby, had been going to the center and saw things that concerned her," said John Jones, program director for the Mental Health Advocacy Program, which is part of the Disability Rights Center. "We took the pictures, and we gave them to the state."
Hanley said he was stunned when he saw the conditions in the pictures.
Learning that Looney owned three other facilities, two with her son, Hanley sent Floyd Sparks, administrator of the Medicaid Field Audit Unit, to inspect the others and bring back more pictures.
"I had lost confidence in the residential care facility surveyors. It was obvious these places probably should have been shut down a good while ago or forced to clean up," Hanley said.
Inspection records for Alternatives Plus obtained by the Democrat-Gazette show few violations were cited in 1997. The survey reports were either one or two pages long.
A Feb. 13, 1998, report cites the facility for failure to notify the Office of Long Term Care of a violent incident between two residents on Feb. 5 in which one of the residents was injured.
The incident "was not reported to OLTC until 2/11/98 following the facility being contacted by the DeWitt police department [who were] investigating a suspected abuse complaint reported by another healthcare provider," the report says.
During the next inspection on Aug. 20, 1998, surveyors discovered numerous violations, including another violent act.
"On 8/12/98 a resident obtained a knife in the kitchen, threatened several people, and was finally subdued by DeWitt Police [who had] to spray half can of mace on the resident. This incident was not reported to the Office of Long Term Care as required."
During that same Aug. 20 survey, inspectors discovered that Alternatives Plus had violated the state's minimum staffing requirement.
"On 5/10/98 an accident involving a resident occurred, and the resident was transported to the hospital by the police department. ... The CNA in charge offered to send a resident to pick him up because she was the only employee on duty on the premises," the report stated.
Mark Hemingway, director of the Office of Long Term Care, said he is revising the way inspections are conducted.
"The inspectors were citing problems but were not going the next step. We should have been following up, and as of now we are going to be."
He said inspectors will take cameras into the facilities to document problems and make it easier to revoke licenses.
Inspections are overseen by Jerry Rayburn, who works for the Office of Long Term Care. He was reinstated in early November after being placed on a seven-month administrative leave during a separate investigation of his office.
Joe Quinn, a Human Services Department spokesman, said the actions of all employees of that unit are being reviewed.
"We will continue to look at why enforcement wasn't aggressive enough," he said. "On a human level, these pictures are extremely troubling. I don't want anyone to get the impression they don't bother people here."
Inspectors were sent within the past week to 20 other facilities on the basis of tips and complaints.
"The concentration of our staff has been on nursing home inspections," Hanley added. "And, frankly, we haven't paid enough attention to the residential care facilities. We are starting to correct that."
David Ivers, attorney for the Arkansas Residential Assisted Living Association, sent a letter to the Human Services Department asking officials why state Medicaid auditors had not given five days notice of their inspections.
"We did that in the past as a courtesy," Hanley said. "We have the authority to go into these places any time. I don't know why they want to talk about that and not the squalid condition these people are living in."
For now, the state must decide where to place the residents of the three facilities facing revocation.
"We have places for 40 out of approximately 100 residents. Mental health experts will be going in there Monday to help assess each person," Hanley said.
"I don't think that's too hasty," he said. "Not after seeing those pictures. It's a necessity. These are mentally ill people who have been found disabled and have placed themselves in the care of these four facilities. So these are not able-minded, able-bodied people who went out and rented an apartment."
Jones of the Disability Rights Center said his organization will be involved in the relocation of the residents. "We are concerned that the people who live in these places have as much say as possible about where they live next," he said.
Hanley stressed that he did not think the pictures were representative of most residential care facilities.
Kent Schroeder, executive director of the Arkansas Residential Assisted Living Association, said he had heard about the pictures of the four facilities but was still surprised when he saw them.
"They were bad," he said. "In no form or fashion does the association condone dirty or unsanitary facilities, and that is certainly not a common occurrence. There's no excuse for that. After viewing the pictures, I can't believe this has really happened. I was very disappointed.
"The filth shouldn't be allowed. It just shouldn't be allowed. If you had asked me two weeks ago, I would have said this couldn't have happened."
Schroeder, who is also an administrator of Graham's Foster Home in Cabot, said he expects the association to ask Alexander to resign from its board of directors.
Association representatives and Human Services Department officials disagree whether the centers have adequate funding.
"While this is no excuse for what happened in those facilities, the program is underfunded," Schroeder said. "The state has woefully underfunded and ignored the pleas of providers who care for the mentally ill. It is unreasonable to expect high quality of care with these rates.
"When you are caring for a population that is predominately mentally ill, you have certain individuals that, at times, become destructive. So there is not enough money generally for facilities to maintain their repairs and get the minimum level of care based on $470 a month."
But Hanley said the $470 from Social Security, which is often combined with nearly $800 a month from Medicaid per resident for personal care, is plenty.
"Would you pay $1,300 a month to put someone in the squalor we photographed?" he asked. "To imply we have treated them unfairly under existing rules is not right."
Hanley said he would like to work with the association in the future.
"I want to encourage them to help by policing their own industry," he said. "Then we can either get these bad facilities cleaned up or shut down so they can provide services and do it right."
Schroeder said the industry is also concerned about providing good care.
"This situation underscores the need for quality-of-care issues to be addressed more diligently by this association and the industry. And it's too important to be left solely to the discretion of the regulators," he said.