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The Arizona State Hospital is located on a 260 bed 93-acre campus in Phoenix providing inpatient psychiatric care to people with mental illnesses who are under court order for treatment.  Treatment at ASH is considered “the highest and most restrictive” level of care in the state. Patients are admitted because of an inability to be treated in a community facility or because of their legal status.

The Civil portion of the hospital provides services to people civilly committed as a danger to self, danger to others, gravely disabled and/or persistently and acutely disabled. Forensic patients are court-ordered for pre- or post-trial treatment because of involvement with the criminal justice system due to a mental health issue.

The needs of patients at ASH can be complex and the patients are vulnerable, so it’s critical to ensure the facility uses best practice treatment and is following a rigorous set of regulations. To achieve fidelity to best practice standards, it’s critical that the governance structure ensures accountability and is free from conflicts of interests.

The Problem

The existing governance structure is insufficient to ensure quality care is provided at ASH. The fundamental flaw is that ADHS both runs & regulates ASH.

The lack of independent regulation & oversight of the Arizona State Hospital results in poor accountability and can lead to unchecked substandard care when ADHS leadership soft-pedals regulatory oversight to give the appearance that the facilities are providing care that meets standards.

There is evidence that this occurred during the Ducey Administration.  For example, in 2021, ADHS’ licensing division investigated multiple suicides and a homicide and concluded that no operating deficiencies led to those deaths. Suicides and homicides only occur when there are deficient practices.

For context read this article by Amy Silverman: Patient deaths at Arizona State Hospital raise questions about staffing levels, lack of oversight and this piece by Mary Jo Pitzl at the Arizona Republic

The Solution

AzPHA is a supporter of SB1710 because it is a commonsense solution to governance problem that’s jeopardizing care at ASH by separating the operational functions of running ASH from the regulation of ASH by creating two separate entities (ASH would no longer be a part of ADHS).

The bill would establish a 5-member State Hospital Governing Board and transfer operational responsibilities to the Board. Members of the governing board would be appointed by the governor. The ASH Superintendent would report to the governing board rather than the ADHS Director. ADHS would then regulate the facility without an institutional conflict of interest.

[SB1710 passed the full Senate with a vote of 27-2 and has passed all assigned committees in the House. It awaits a final floor vote in the AZ House of Representatives. If it isn’t amended on the House floor and passes, it would go to Governor Hobbs’ desk for a signature.]

ADHS leadership has suggested that there is sufficient independent oversight of ASH, an oft told and misleading statement designed to give the impression that separating ASH from ADHS is unnecessary. To clear things up, we prepared this review of how the Arizona State Hospital is ‘regulated’ under the current model and why SB1710 is so important.

Civil Hospital

The ASH Civil Hospital provides treatment and care for persons that are court ordered to the facility for psychiatric care.  The Civil Hospital at ASH is run and regulated by the Arizona Department of Health Services (ADHS). ADHS’ Licensing Division is responsible for regulating the Civil Hospital which the ASH Superintendent is responsible for its operation.

State law allows healthcare institutions like ASH’ Civil Hospital to enjoy a Deemed Status license from the ADHS. That means that the Civil Hospital can hire an accrediting body to accredit the Civil Hospital. Once accredited, the Civil Hospital turns in the accrediting report to the ADHS Licensing division, and the ASH Civil Hospital receives a License from the ADHS – even though the ADHS doesn’t do an inspection of the facility before issuing the license.

ADHS pays The Joint Commission to accredit the Civil Hospital, which gives the facility a deemed-status license from ADHS. ASH Civil started hiring TJC to do that work when I was Director. I think we paid TJC something like $10K for that service. Here’s a link to the deemed status licensing information about the Civil Hospital: Licensing Statement of Deficiencies.  ADHS accepts the accreditation in lieu of an inspection and issues the state license to operate on that basis.

ADHS doesn’t do any annual inspections of the Civil Unit to ensure compliance with state licensing criteria because of its ‘Deemed Status’.  ADHS’ Licensing division can send out surveyors to investigate complaints about the care at the Civil Hospital when they receive them. If the complaint is substantiated, the ADHS Licensing Division can require corrective action and has some enforcement authority like issuing civil money penalties or placing the facility on a provisional license or even seeking revocation.

During the Ducey administration, ADHS ‘complaint investigations’ seldom substantiated the complaints they receive and seldom find deficiencies (with a few exceptions), even after suicides. Here’s the recent compliance record: Licensing Services Facilities Report

Because Medicare and Medicaid (AHCCCS in Arizona) pay for some of the services at the ASH Civil Hospital, CMS requires ASH’ Civil Hospital to be Certified to their certification standards. However, CMS doesn’t do their own certifications. They contract with the ADHS Licensing staff to conduct the certification surveys.

ADHS licensing staff go out and check at the ADHS ASH Civil Units to see if they’re adhering to CMS’ certification standards (which are a little different from the actual ADHS healthcare Institution regulations). ADHS Licensure then sends their report to CMS Region IX in San Francisco and the report is blocked, copied, pasted, and is sent back to ADHS and ASH on CMS letterhead.

ADHS both runs and regulates the ASH Civil Hospital. ADHS leadership often suggest that there are checks and balances in the regulatory system to send the message that the monitoring of care is rigorous. CMS Certification is not an independent review of care at the Civil Hospital because the work is conducted by ADHS Licensing staff.

While it’s true that The Joint Commission accreditation is separate from ADHS, the agency pays TJC for the accreditation surveys. TJC views ADHS as a customer/client. It is not a regulatory body, and they have no enforcement authority. TJC Accreditation inspections that document deficiencies can sometimes jeopardize their contract with their customer, having a chilling effect on documenting deficient practices.

Forensic Hospital

ASH’ Forensic Hospital provides care for patients that are determined by the courts to be “Guilty Except Insane” or “Not Guilty by Reason of Insanity”.  The Forensic Hospital is also both run and ‘regulated’ by ADHS.

State law allows ASH’ Forensic Hospital to enjoy a Deemed Status license from the ADHS. That means the Forensic Hospital can also hire an accrediting body to accredit the Forensic Hospital. Once accredited, the Forensic Hospital turns in the accrediting report to the ADHS Licensing division and receives a License from the ADHS – even though the ADHS doesn’t do an actual inspection of the facility. ADHS also pays the Joint Commission to accredit the Forensic Hospital.

When ADHS’ Licensing division receives complaints about care at the Forensic Hospital they can send out surveyors to investigate those complaints. If the complaint is substantiated, the ADHS Licensing Division can require corrective action and has some enforcement authority like issuing civil money penalties or placing the facility on a provisional license or even seeking revocation.

During the Ducey administration, ADHS ‘complaint investigations’ seldom substantiated the complaints or identified deficiencies (with some exceptions). Here’s the recent compliance record: Licensing Services Facilities Report (azdhs.gov)

Conclusion

The current governance structure for operating and regulating the Arizona State Hospital is fundamentally flawed because the ADHS both runs and regulates the hospital. The lack of independent regulation and oversight results in poor accountability and can lead to unchecked substandard care when ADHS leadership soft-pedals regulatory oversight to give the appearance that the facilities are providing care that meets standards. There is evidence that this occurred during the Ducey Administration.

SB1710 reforms of the governance structure by removing ASH from ADHS. It would separate the operational functions of ASH from the regulatory responsibilities by creating two separate entities (ASH would no longer be a part of ADHS). A 5-member State Hospital Governing Board would be responsible for the oversight of ASH and the Superintendent would report to the Board rather than the ADHS Director. ADHS would then regulate the hospital without an institutional conflict of interest.