Report: ADHS Does Not Investigate Complaints in Nursing Homes


“That shouldn’t happen,” said Acting ADHS Director Don Herrington. “Family members need to know what’s going on.”

Arizona, United States — Arizona Department of Health Services has improperly investigated complaints, if at all, for years, according to a new report released by the Arizona 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 improperly closed most high-priority complaints without on-site investigation required, including complaints of abuse or neglect.
  • ADHS failed to initiate on-site investigations for nearly three-quarters of its high-priority complaints
  • The Ministry has “inappropriately” amended the complaint statutes to extend the required response times for complaints.

The tracking 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 constitute something that “impairs a resident’s mental, physical and/or psychosocial state, or health and safety risks that may exist and are likely to cause a significant problem in care and treatment, but which does not rise to the level of an immediate and serious threat. ADHS is supposed to conduct an on-site inspection within 10 days if a complaint is deemed high priority.

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

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

Findings: Complaints dismissed without investigation; downgraded to priority

The audit determined that ADHS failed to investigate according to Centers for Medicare and Medicaid Services (CMS) investigation requirements and that “investigation failures” put residents of long-term care facilities at risk duration such as retirement homes.

For example, the audit details that in October 2020, ADHS received a complaint regarding the care of a non-verbal dependent resident in a long-term care facility. ADHS called this complaint sexual abuse and ranked it high priority, but did not send anyone to take immediate action as per CMS requirements. The audit claims the ministry failed to carry out the required on-site inspection and could not prove whether sexual abuse took place. The complaint was finally dismissed eight months later without the Department taking any action against the staff because it did not 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 at an unnamed long-term care facility who had unexplained bruises and a sore tailbone after being soiled for long periods. Once the department received the complaint, it listed seven different allegations to investigate and categorized the complaint as a 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 clarifies that the Department received an abuse complaint in December 2018. This complaint was rated 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 opened 14 months later in February 2020.

The audit also accuses ADHS of inappropriately reassigning the majority of its high-priority open cases to medium- or low-level priorities, which do not need to be reviewed as quickly.

Other concerns detailed in the audit include Department staff not being familiar with CMS requirements; ADHS “inappropriately” closes pending complaints and public lacks confidence in ADHS.

Arizona Department of Health Services Responds

Acting ADHS director Don Herrington said he and his staff saw the report earlier in the month and asked the Office of the Auditor General to provide more details so his department could investigate internally. . He said he didn’t know if any of the allegations were true, but would look into it.

“If we’ve done something wrong, we can take steps to correct it,” he said.

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

“I think the point is that we’re a unit here, no matter who’s sitting in what chair,” Herrington said. “And we will admit the things that we should admit and if there is a dispute on our part, we will dispute it as well.”

As for allegations that complaints, including abuse, are not being investigated on time or at all.

“That shouldn’t happen,” Herrington said. “Family members need to know what’s going on.”

The follow-up report stemmed from a State Audit 2019 which concluded that the ministry “failed to investigate or timely investigate certain complaints from long-term care facilities”. The follow-up report found that ADHS had not implemented any of the recommended changes for improvement detailed in the 2019 audit.

The new report details “a shortage of staff or the COVID-10 pandemic do not explain the issues we have identified in this follow-up report.”

Herrington disagreed, saying they were operating with a reduced staff and had limits on inspections due to COVID-19 concerns and policies. He also said the priority had been changed to ensure healthcare facilities had COVID-19 control policies in place.

“Most of the people doing this type of work are nurses and nurses were in high demand for all kinds of medical facilities and especially medical facilities that could pay a lot more than we paid,” Herrington said. “We turn around a lot.”

He said staffing is still a concern more than two years into the pandemic. Currently, he said there are a dwindling 15 investigators handling complaints from long-term care facilities. He said he was working with the Arizona Department of Administration to try to raise salaries to recruit and retain people for those roles.


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