Will Humble Assurance & Licensure, Healthcare, Wills Blog

Auditor General’s Office Produces Scathing Review of ADHS’ Nursing Home Complaint Investigations During the Director Christ Era

Auditor General’s Report of the Arizona Department of Health Services Nursing Home Complaint Investigation Performance

Every 10 years the bigger state agencies go through what’s called a Sunset Review – which is the state legislature’s way of examining the performance of state agencies and determining whether they still need to exist or require major reform. The legislature often asks the Auditor General’s Office to review the performance of specific areas and write a report.

That Sunset Review for ADHS happened back in 2019. The Auditor General reviewed ADHS’ performance with respect to following up on nursing home complaints (ADHS is the regulatory authority for nursing homers).

That 2019 Arizona Auditor General Report found, among many other things, that ADHS (during the Director Christ era) failed to investigate, or timely investigate or resolve many long-term care facility complaints. The report laid out 4 key areas where performance improvement was needed. Director Christ (and Deputy Colby Bower) made promises at the time to make the improvements. The state legislature even followed through, giving the agency an additional $1.6M to hire staff.

The auditor general’s team came back in 2021 to see whether the ADHS had made any improvements. Astonishingly, the report issued this week concluded that the agency had not implemented any of the required changes, and also found these disturbing findings:

  • Between 7/1/19 and 4/21/21 ADHS, under the leadership of former Director Christ and Assistant Director Colby Bower, lowered the priority level of 98% of their open high priority complaints, giving them months more time to investigate and giving the appearance they were making improvements (high risk complaints need to be done in 10 days vs months for the others).
  • ADHS leadership CLOSED 79% of those former high priority complaints without ever doing an investigation.
  • ADHS leadership CLOSED 82% of high priority facility self-reports after changing them to medium and then closing without an investigation.
  • In the second half of 2019 (before the 1st auditor general report) ADHS had classified 42% of nursing home complaints as high risk. After the report was published – the percentage of complaints classified as high risk dropped to only 4% (July – Dec. 2020).
  • ADHS did not post complaints on AZCARECHECK (the public disclosure site) unless there was an investigation…  but because they closed out the vast majority of complaints without an investigation, thousands of those complaints never made it to their website- further greatly limiting the ability of family members to make informed decisions.

The interim joint committee of reference is asking for quarterly reports from ADHS, told ADHS to be transparent about how they classify complaints, legislature will make sure CMS knows about the audit reports, the ADHS is supposed to fully cooperate with the auditors on follow ups. No mention of the committee urging state or county law enforcement investigations though.

Note: To be fair to the current ADHS leadership team- the review period for the Auditor General’s Report was from July 1, 2019 through April 21, 2021. Director Christ was the agency director for that entire period and Colby Bower was the head of Licensing. Both of those persons left the agency in late 2021 and now are in well paying senior leadership positions at Blue Cross Blue Shield of Arizona.

AZ failed to properly investigate nursing home complaints
Read the ADHS Auditor General’s Report
Arizona regulators skipped inspections of long-term care facilities

From the new Auditor General Report:

‘As described in the transmitted follow-up report, we found that the Department has not implemented any of the 5 recommendations from our September 2019 report, and we identified additional significant complaint-prioritization and investigation failures that have continued to put long-term care facility residents’ health, safety, and welfare at risk.’ For example:

  • Contrary to federal requirements, the Department inappropriately closed most High-Priority complaints/self-reports without a required on-site investigation, including complaints involving allegations such as lack of pressure sore precautions, residents being left soiled for an extended time, and abuse or neglect.
  • Of the 156 High-Priority complaints the Department investigated, it failed to initiate the on-site investigations for 73% of these within the required 10 working days. 
  • The Department inappropriately changed 98% of its open High-Priority complaints to lower priorities, which artificially extended the time frame for responding to these complaints/self-reports from 10 days to 1 year.
AZ failed to properly investigate nursing home complaints, report says

The key to whether the agency fixes these potentially lethal deficiencies lies with whether Interim Director Herrington admits to the program failures and commits to fixing the problems. If he stonewalls as his predecessor did, we will likely be stuck with poor performance until the next administration.

Will Humble Disease Control, Wills Blog

Is Monkeypox Reportable in Arizona?

Monkeypox was first discovered in 1958 when two outbreaks of a pox-like disease occurred in colonies of monkeys kept for research, hence the name ‘monkeypox.’ The first human case of monkeypox was recorded in 1970 in the Democratic Republic of Congo during a period of intensified effort to eliminate smallpox.

Monkeypox Background

Monkeypox cases in people have occurred outside of Africa linked to international travel or imported animals, including cases in the United States, as well as Israel, Singapore, and the United Kingdom. The natural reservoir of monkeypox remains unknown. However, African rodents and non-human primates (like monkeys) may harbor the virus and infect people.

Case Definition | Monkeypox

Transmission of monkeypox virus occurs when a person comes into contact with the virus from an animal, human, or materials contaminated with the virus. The virus enters the body through broken skin (even if not visible), respiratory tract, or the mucous membranes (eyes, nose, or mouth). Animal-to-human transmission may occur by bite or scratch, bush meat preparation, direct contact with body fluids or lesion material, or indirect contact with lesion material, such as through contaminated bedding. Human-to-human transmission is thought to occur primarily through large respiratory droplets.

Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Other human-to-human methods of transmission include direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens.

Note: Monkeypox is not a reportable disease in Arizona, however ARS 36-621(H) gives the ADHS Director the ability to temporarily add the disease to the reportable list for up to 18 months. I have no idea whether they have contemplated doing that yet or not. The ADHS should have done a HAN (Health Alert Network) notice to clinicians last week with the case definition information by now, but I don’t know if they’ve done that or not yet.

Will Humble Disease Control, Vaccination, Wills Blog

Arizona’s Influenza Epi Curve Has a Double Peak for the First Time Since 2009

I was looking at the latest Influenza Surveillance Report the other day and noticed that Arizona’s influenza epi curve has a double peak, which is very unusual. I went into the archive reports and discovered that this is the first time since 2009 with a double-peak epi curve. The double peak epi curve in ’09 was of course because of the H1N1 influenza pandemic which arrived late in the flu season and caused an unusual summer peak.

Because a double peak is such a rare event- there has to be something going on. My working theory is that a fair number of folks were still wearing face masks in public during out huge Omicron wave- which had the effect of suppressing influenza transmission. When masks dropped this spring that gave the virus a new opportunity to amplify.

I can’t prove it, but that’s the only thing that makes sense to me.

Will Humble AzPHA Breakfast & Learns, Behavioral Health, Wills Blog

Webinar Update from the Field- Prevention & Treatment of Substance Use In Arizona: AHCCCS’ Action Plan

Friday, May 27, 2022   9-10am AZ Time

Session Summary

This important AzPHA Breakfast & Learn will highlight Arizona Health Care Cost Containment System’ (AHCCCS) grant funded programming to improve access to services for individuals who experience substance use disorder. We will also cover prevention activities underway among Medicaid members to reduce the prevalence of substance use disorder and drug-involved overdose deaths for Arizonans. 

View the Webinar


Hazel Alvarenga (she/her) is Deputy Assistant Director of the Division of Grants Administration at the Arizona Health Care Cost Containment System. She oversees the programmatic and finance units that manage day-to-day federal block and discretionary grant activities with the aim to increase services for individuals in need of mental health and substance use disorder services.

Register Here

Where: Zoom (registrants will receive the link) 

When: Friday, May 27, 2022   9-10am AZ Time

Cost: Free for AzPHA Members!

Will Humble Firearm Safety, Prevention, Wills Blog

There Are Well-Established Evidence-Based Solutions to Preventing Firearm Violence

We Just Need Our State & Federal Elected Officials to Care Enough to Implement Them

Like all of you, I watched and read about last week’s mass shooting with horror. Most Americans watched this recurring tragedy and said: “we need to do something”. In fact, there’s majority support for evidence-based interventions like universal background checks, Red Flag laws, a higher age requirement to buy firearms, and bans on semi-automatic assault rifles.

But sadly, there are also millions of Americans who apparently care more about a perceived threat to their arsenal than about the lives of schoolchildren or are simply indifferent to the carnage. Far too many politicians either don’t care about the firearm violence, are too far deep into the pockets of the gun lobby or are simply scared of losing power in their ‘safe’ districts where it’s popular to resist all firearm interventions.

As public health practitioners, we are in the best position to identify evidence-based practices that will save lives. Implementing those interventions, however, is political. This probably sounds defeatist, but at the federal level, it looks like there’s not enough political will to implement interventions to mitigate the carnage. In part, that’s because of people like Senator Sinema who are unwilling to waive filibuster to pass two evidence-based bills that have already passed in the US House of Representatives:

At the state level, the opportunities to implement helpful interventions are even fewer right now as current legislative leadership is more interested in passing laws that make things worse rather than better.

While the opportunities to pass laws at the federal and state level appear grim, that doesn’t mean that it will always be that way. When the tumblers finally click public health needs to be prepared to identify and recommend effective evidence-based interventions to inform policymakers. What does an evidence-based approach look like?  Below are some of the highlights.

Step 1 — Define the problem

Researchers and policymakers need reliable data to understand the scope and complexity of gun violence. There are many different types of gun violence, and each type often requires different prevention strategies. Collecting and distributing reliable firearm data is essential to combating gun violence through a public health approach.

Gun violence prevention researchers need reliable and timely data around the number of firearm fatalities and nonfatal injuries that occur in the United States each year. This data should include the demographics of the victim and shooter (if applicable), the location and time of the shooting, and the type of gun violence that occurred. Databases should classify the types of gun violence (suicides, intimate partner violence, mass shootings, interpersonal violence, police shootings, unintentional injuries) based on clearly defined and standardized definitions. This data should be made widely available and easily accessible to the public free of charge.

Step 2 — Identify risk and protective factors

The public health approach focuses on prevention and addresses population level risk factors that lead to gun violence and protective factors that reduce gun violence. A thorough body of research has identified specific risk factors, both at the individual level and at the community and societal level, which increase the likelihood of engaging in gun violence.

At an individual level, having access to guns is a risk factor for violence, increasing the likelihood that a dangerous situation will become fatal. Simply having a gun in one’s home doubles the chance of dying by homicide and increases the likelihood of suicide death by over three-fold. Other individual risk factors closely linked to gun violence include: a history of violent behavior, exposure to violence, and risky alcohol and drug use.

Community level factors also increase the likelihood of gun violence. Under-resourced neighborhoods with high concentrations of poverty, lack of economic opportunity, and social mobility are more likely to experience high rates of violence. These community level factors are often the result of deep structural inequities rooted in racism. Policies and programs should mitigate risk factors and promote protective factors at the individual and community levels.

Risk factors for suicide include easy access to lethal means, family history of suicide, previous suicide attempt(s), a history of mental illness, a history of risky alcohol or substance use, feelings of hopelessness or isolation, and others. By identifying these risk factors and thus further defining who is at risk, we can more effectively develop strategies to address these risk factors and prevent firearm suicide.

Step 3 — Develop and evaluate prevention strategies

Policymakers and practitioners must craft interventions that address the risk factors for gun violence. These interventions should be routinely tested to ensure they are effective and equitable; rigorous evaluations should be conducted on a routine basis.

The foundation for effective gun violence prevention policy is a universal background check law, ensuring that each person who seeks to purchase or transfer a firearm undergoes a background check prior to purchase.

Universal background checks should be supplemented by a firearm licensing system, which regulates and tracks the flow of firearms, to ensure that firearms do not make it into the hands of prohibited individuals.

Building upon this, policymakers can create interventions that target behavioral risk-factors for gun violence (e.g., extreme risk) and they can push for policies that address community risk factors that lead to violence (e.g., investing in community-based violence prevention programs).  Extreme risk or ‘Red Flag’ laws are also an effective prevention tool. These evidence-based laws take risk factors for harm to self or others into account and allow family members and/or law enforcement to petition a court to temporarily remove firearms until the period of heightened risk has passed.

A higher age requirement to buy firearms is an effective way of delaying the purchase of firearms until the maturation of the prefrontal cortex occurs (at age 25), reducing the frequency of impulse purchases that result in homicide, suicide, and mass killings. Banning the sale of assault rifles mitigates the scale of mass shootings when they occur (although the number of assault rifles in the possession of Americans has already gone from 400,000 to more than 20,000,000 since the assault rifle ban ended in 2004).

Based on the information gathered in the first two steps, public health professionals, policymakers, and others create data-driven interventions. These include policies and programs that address the risk factors and root causes of gun violence and target solutions to best serve at-risk populations.

Step 4 — Ensure widespread adoption of effective strategies

Firearm violence prevention public policy is only effective if they are properly implemented, and people understand how to use them. Implementation and evaluation of these initiatives should be conducted at the federal, state, and local levels as applicable.

For firearm suicide prevention, this means training the proper stakeholders, such as law enforcement and judges, and ensuring that new policies and programs to prevent firearm suicide — like extreme risk laws — are being properly adopted.

AzPHA’s Action Plan

For our part, AZPHA is in the process of providing a paid internship to a student to characterize the extent of firearm violence in Arizona. We believe we must do this because we have no confidence that the Arizona Department of Health Services (under current leadership) is willing to do so. The scope of work is to essentially provide an epidemiological and evidence-based recommendations for Steps 1, 2 and 3 above (focusing on state-level data and interventions):

  • Step 1 — Define the problem
  • Step 2 — Identify risk and protective factors
  • Step 3 — Develop and evaluate prevention strategies

Editorial Note: The continuing violence in Arizona and the U.S is disturbing and tragic and much of it is preventable. As public health professionals, we’re unable to take on the entire problem because implementing the solutions requires electing enough persons to public office at the state and federal level that care about this problem enough to implement policy interventions. But we can, and will, play a role in informing evidence-based policies that will work. We can also all be committed to supporting candidates for state, federal and local offices that share our values.

Will Humble Air Quality, Climate Change, Wills Blog

Are Federally Funded Electric Vehicle Charging Stations Coming to Arizona Highway Rest Areas?

It Depends on ADOT’s Leadership Team

The Infrastructure Investment and Jobs Act (IIJA) – (aka the Bipartisan Infrastructure Bill) has $5 billion in funding for states to add electric vehicle charging stations (in a funding formula) and an additional $2.5B in competitive grants. Because ‘range anxiety’ is a big consumer barrier for buying an electric car, the state funding formula focuses on adding charging stations to the interstate highway system in the initial years.

Arizona’s formula funding for the next 5 years totals $76.5M, with $11.3M in year one (2022). To get the federal funds states need to contribute 20% toward the program- which can come from state government, from the private sector, or via a public/private partnership.

There’s a long list of potential partners or sponsors to contribute that 20% including Nikola Corp., Lucid Motors, LG Energy Solutions, Tesla, APS, SRP, or Tucson Electric Power. Because ADOT has administrative control of the rest areas, they should be able to provide incentives or deals attractive for private or public/private partners to chip in for the 20% match.

Each charging station costs about $100K including the administrative costs…  meaning Arizona’s allotment of $11M in 2022 should be enough to put up 110 or so charging stations. With 16 interstate & state highway rest areas in Arizona (some busier than others – Sunset Point being the busiest) there’s sufficient funding in 2022 to put an average of 4 stations per rest stop this year (although it probably makes sense to do more than 4 at the busiest rest stops and fewer at the quainter ones).

To get the finding for the charging stations, ADOT needs to submit an EV infrastructure deployment plan to the Joint Office of Energy and Transportation by August 1, 2022. The decision rests with ADOT, but their plan will be informed by the Arizona State Transportation Board. 

I called into and provided written comments to the AZ Transportation Board public meeting last Friday urging them to charge ADOT with finding a workable plan that places the stations in convenient places (at rest areas) while providing incentives for private sector participation for the match (e.g., Nikola, Lucid, Tesla, APS, SRP, TEP etc.). The main call to action was to get ADOT to include electric vehicle charging stations in their 5-year plan. At this point, the ADOT 5-year plan doesn’t even mention electric vehicle charging.

In looking at public comments that have been made by Board members, we discovered that they are skeptical of participating even though the feds pay for 80% of the costs. 

But does that resistance make sense? No!  As one of our Board Members, Mac McCullough (a health economist), explains here…  there are many rational reasons why the government should invest in emerging markets especially when their products have tangible public health benefits. From Dr. McCullough:

  • Gas stations are a mature market whereas electric charging stations are a very new/emerging market. Government involvement in new or emerging markets is far more common—and economically rational—than government involvement in mature markets.
  • A first-mover disadvantage exists where consumers shy away from EVs due to “range anxiety” since relatively few EV charging stations exist. This leads to a smaller EV market share, which leads to fewer EV charging stations being built. Which leads to more “range anxiety.” Basically, if you don’t build it, they won’t come.
  • EV charging stations face a first mover disadvantage (nobody has much incentive to build the first EV charging station but once others exist the incentive changes/grows). This means that we should not necessarily expect the private market alone to quickly create a robust charging network.
  • Compared to electric-powered vehicles, gasoline-powered vehicles impose much different societal costs in terms of externalities. When there are externalities—meaning the full costs of consumption of a product are not borne by the producer/consumer—there is some rationale for government involvement in the market. This is especially true when the mature market has externalities that the emerging market can help reduce.
  • Simple market forces won’t necessarily produce a coordinated network of charging stations. The tragedy of the commons suggests that while overall EV producers (and society) will recognize the value of a robust, coordinated network of chargers, there’s little incentive for any one EV company to build this on their own. It makes more sense for any given company to sit on the sidelines while the other companies pay for things.

Time will tell if ADOT puts in a plan. If they don’t, the program goes for another 5 years – and the next administration can participate. Elections matter! 

Will Humble Early Childhood, Prevention, Vaccination, Wills Blog

Legislative Roundup: Ducey Signs Two More Harmful Preemption Bills

As expected, the legislature passed two harmful bills last week on a party-line vote & Ducey promptly signed both. HB2453 prohibits the state or any political subdivision from requiring people to wear a mask on their premises. There’s an exemption for places like Valleywise Health. This law will be quite harmful if it’s not repealed before the next time we have an outbreak of an airborne illness.

He also promptly signed HB2086 which will prohibit the ADHS from ever adding the COVID vaccine or it’s successors to the list of vaccines required for school attendance. See: COVID-19 vaccine for school kids not required after Ducey signs bill.

Editorial Note: This new law is totally unnecessary. The existing process for adding school required vaccines has been in place for decades and works well. ADHS has to do a rulemaking (with lots of public comment), and economic impact evaluation, and final approval rests with the Governor’s Regulatory Review Council.

Back in 2008 we added the Varicella (chicken pox) and Meningococcal vaccines to the list required for school attendance. We listened to & learned from the public comments & made sure the epidemiology & economics made sense. 

Here’s an op-ed by Leslie Maier who was instrumental in inspiring us to add the meningococcal vaccine to the school required list. In it she talks about losing her son Chris to meningitis at the age of 17: Arizona vaccination rates are lagging. That’s even more dangerous now

BTW: Here are the results of our 2008 intervention (for Meningococcal disease):

Uptake of Meningococcal Vaccine in Arizona Schoolchildren after Implementation of School-Entry Immunization Requirements.

“During SY 2006–2007, only 20.1% of 11-year-olds and 21.0% of 12-year-olds in the registry received the meningococcal vaccine. This proportion increased during SY 2007–2008 to 48.2% of 11-year-olds and 40.3% of 12-year-olds. The increase in on-schedule vaccination rates between 2007 and 2008 was statistically significant (Pearson’s corrected Chi-square value 5 2,426.07, degree of freedom 5 1, p,0.0001) at 95% CI.”

“This analysis suggests that implementation of school immunization requirements resulted in increased meningococcal vaccination rates in Arizona, with degree of response varying by demographic profile. ASIIS was useful for assessing changes in immunization rates over time.”

I’ll be presenting about the various preemption bills (ppt) that Ducey signed at the June 14, 15 Rural Health Conference in Flag. More info about registration here: 48th Annual Arizona Rural Health Conference | Arizona Center for Rural Health.

Will Humble Professional Development, Wills Blog

AzPHA President Elect & Author Kelli Donley Williams Has A New Book: DESERT DIVIDE

From the author of the acclaimed novel Counting Coup comes Desert Divide, a gripping, ripped-from-the-headlines story of family, revenge, and justice spanning the ranches of southern Arizona to the dinner tables of Mexico City’s elite. It’s 2016.

Sarah McDaniels receives a call in the night that her mother has died unexpectedly. Returning to the family’s ranch in the high desert of southeastern Arizona, Sarah finds her childhood home and her father’s health in tatters.

More than a decade ago, Sarah left to chase a dream in New York City. Now, faced with burying her mother and trying to arrange care for her father, Sarah takes a walk across the family’s land to clear her head. When she stumbles over something on the desert floor, the last thing she expects to find is the body of a young woman her own age.

Who was this woman? Why was she on their family’s ranch? Who killed her?

Desert Divide is a true-to-life story of secrets, sacrifice, and redemption as one woman tries to face down her demons while saving what’s left of her family.

We encourage you to get Desert Divide at your local bookstore (like Changing Hands) but you can also find it on Amazon Desert Divide – Kindle edition by Donley , Kelli. Literature & Fiction Kindle eBooks @ Amazon.com.

About the author: Kelli Donley is a native Arizonan. She is the author of four novels, Under the Same Moon, Basket Baby, Counting Coup, and Desert Divide. Inspiration for this novel was found after seeing an exhibit of the Migrant Quilt Project. Kelli lives with her husband Jason, animals, and unruly vegetable garden in Mesa, Arizona. She works in public health, and blogs at: www.africankelli.com

Will Humble Community Health Workers, Professional Development, Wills Blog

Community Health Worker Training Program

Deadline Approaching

Community Health Workers are frontline public health workers who have a trusted relationship with the community and facilitate access to a variety of services and resources for community members. Building CHWs into the continuum of care has been proven to both improve health outcomes and reduce healthcare costs.

For a picture of how CHWs can fit into a continuum of care, take a look at this report from the NAU Center for Health Equity Research in collaboration with the UA Prevention Research Center (AzPRC) which provides insight into innovative strategies for integrating, sustaining and scaling of the CHW workforce within Medicaid (AHCCCS).

Building CHWs into the healthcare continuum requires that a certification process be in place. The public health community tried for many years to get such a process in place, finally meeting with success 4 years ago with the passage of HB 2324 (sponsored by Representative Carter), which charged the ADHS with implementing a program for the voluntary certification of Community Health Workers.

After 4 years of anticipation (and advocacy trying to get the ADHS to write the rules) the agency is finally adopting those rules, meaning we are finally on the threshold of bringing CHW’s into the care network.

The US Department of Health & Human Services recently announced availability of $226.5 million for a new program building the pipeline of public health workers at the community level.  The multiyear effort will support training and apprenticeship programs for the critical role of trusted messenger connecting people to care and support. 

Administered through HRSA’s Bureau of Health Workforce, the program will train as many as 13,000 community health workers who will address needs in rural and underserved communities.  These roles, providing culturally competent and individualized services, are critical in rural areas where health services are limited. 

Interested folks can Apply for New Community Health Worker Training Program – but the Deadline is June 11. 

Registration is still open for the annual AZCHOW conference : Roots Annual Conference Tickets, Wednesday, June 22, 23 2022

Roots: The Beginning of the CHR CHW Movement | Recognizing a Resilient Workforce

Vee Quiva Hotel & Casino, 15091 South Komatke Lane, Laveen Village, AZ 85339

Will Humble Healthcare, Professional Development, Wills Blog

Deadline Approaching to Apply for Arizona’s Primary Care Loan Repayment Programs

Arizona has several successful loan repayment programs for primary care providers designed to incentivize them to practice in rural and underserved parts of the state. In exchange for a commitment to serve, providers can get direct relief for a significant portion of their student loans.

The Arizona State Loan Repayment Programs include the Primary Care Provider Loan Repayment Program for public, non-profit providers and the Rural Private Primary Care Provider Loan Repayment Program for providers in rural private practice sites.

Arizona’s State Loan Repayment Program is currently accepting applications for an initial two-year commitment, but the June 1 application deadline is rapidly approaching. Interested providers should review the Provider Application and Program Guide before submitting their application online. To apply, please sign up and access our PCO Portal, by clicking here. 

Below are some additional resources to assist providers in successfully applying:

These programs aim to promote the recruitment and retention of health care professionals by repaying their qualifying educational loans in exchange for their two-year commitment to provide primary care services in federally designated Health Professional Shortage Areas (HPSA) or Arizona Medically Underserved Areas (AzMUA)

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