ComCare Didn't Care

State probe finds that agency's "failure to comply" with regulations contributed to veteran's death

A state agency has concluded that ComCare failed dismally in its treatment of a mentally ill Vietnam veteran who died after collapsing on a Phoenix street.

The investigation by the Division of Behavioral Health Services came in the wake of New Times stories about the life and death of Donald Ellison. The 48-year-old Phoenix resident died of heat-related organ failure last July 26, a day after his release from a county psychiatric ward.

The stories described how ComCare--a taxpayer-funded private agency charged with providing treatment to Maricopa County's 13,000 seriously mentally ill--expedited Donald's dubious release from a psychiatric ward, failed to properly monitor him, and, finally, failed to notify police or his guardian/conservator after he disappeared.

An example: ComCare caseworkers who were supposed to oversee Donald's anti-psychotic-drug intake instead slipped his pills under his apartment door after he didn't answer.

The stories also told how the guardian/conservator--the Arizona Veterans Service Commission (AVSC) and its executive director, Norman Gallion--failed to protect Donald from possible physical harm by not keeping track of him after his release from custody. (AVSC, a state commission, is not affiliated with the federal Department of Veterans Affairs.)

"The investigation found that ComCare staff did not conduct assessments or develop an Individual Service Plan as required," assistant BHS director Rhonda Baldwin wrote in the agency's December 9 decision.

"This failure to comply with [state rules] resulted in a lack of information concerning Mr. Ellison's abilities and needs, inadequate inclusion of relevant parties in decisions concerning discharge planning and lack of any specificity in the actions that were taken following his discharge.

"[This] resulted in an inadequate and undocumented plan concerning the type and frequency of services needed following discharge, how these services would be delivered, outreach efforts required and when modification(s) to the plan would be indicated. . . . By failing to do adequate planning in addressing Mr. Ellison's needs, ComCare did not increase the likelihood that he would benefit from services."

In fact, Donald Ellison, left to his own devices, died.
Baldwin says BHS--part of the state's sprawling Department of Health Services--has ordered ComCare "to develop a corrective action plan which comprehensively addresses BHS's concerns relative to the clinical/supervisory leadership issues which arose from this investigation."

ComCare officials will not comment about specific cases such as Donald Ellison's. However, Baldwin's report indicates ComCare officials have "initiated their own internal investigation concerning this case and have identified and begun to implement corrective action."

According to Baldwin, those corrective actions will include:
"ComCare is drafting a policy which will clearly state that staff are prohibited in engaging in the practice of leaving medications under the door for a client."

ComCare supervisors also are to complete one to two days of training on such seemingly basic issues as "role/responsibility of case managers . . . discharge planning [and] case file review.

"It is expected that staff receiving this training will each repeat the information shared with members of their own clinical teams," Baldwin concluded.

In a related matter, a county court commissioner heard testimony December 10 from an AVSC official who denied her agency failed to serve Donald Ellison in any way.

The two-hour hearing before Commissioner Robert Colosi ostensibly was designed to determine if AVSC misspent Donald's money during the seven-plus years he was the agency's court-appointed ward. (As his guardian/conservator, AVSC controlled Donald's finances, which included payments for his service-connected disability of about $2,200 monthly.)

However, the hearing turned out to be a one-sided affair. The AVSC official, Susan Cooper, painted a rosy but factually skewed picture of an agency that diligently tracked Donald's welfare until his demise.

"We knew what was going on with Donald," Cooper testified as she was questioned by AVSC attorney Harold Merkow and Commissioner Colosi. On the contrary, a relative of Donald's had to inform AVSC on July 31 that Donald had died. And he had been dead for four days by then.

Cooper testified that $620 monthly payments to the Burkeshire Retirement Hotel, a Phoenix boarding home, from April to December 1993 had been passed on by check to Donald by boarding-house personnel. Cooper said the money paid "for his personal allowance and miscellaneous expenses for things that he needed."

That amount, according to AVSC records, was $5,705.
Cooper said AVSC paid Burkeshire $50 per month during that time for daily "medical monitoring" and $25 per month to do Donald's laundry.

But records show Donald apparently wasn't living at Burkeshire during that time. Instead, he was paying rent at an apartment complex miles away--when he wasn't in jail or in a psychiatric ward.

AVSC's own records indicate that the agency itself also disbursed another $1,150 to Donald from April to December 1993 for "personal allowance," $500 for "clothing," $515 for "living expenses" and other expenditures.

That adds up to about $1,000 a month in spending money to a man who, by several accounts, was living a hand-to-mouth existence during that time on the streets of Phoenix.

A nurse who attended the hearing said Cooper's testimony was not credible.
"The idea of Donald Ellison making it down to Burkeshire every day to take his medicine, get his clothes cleaned and pick up his checks is ridiculous," said Randy Brumm, a VA Hospital nurse who treated Ellison on and off for more than a decade. "We'd see him at the VA wearing rags, hungry, straight off the street. . . .

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