MENTAL HEALTH MASQUERADE
Jerry Millison was overcome with anguish on the afternoon of May 12.
"He wondered for a second just how screwed up he had to be before someone would help him," a friend of Millison's recalls.
Millison, 41, had a history of mental illness, substance abuse and three suicide attempts. The most recent one, in August 1994, had landed him in a psychiatric ward.
He'd gotten some dispiriting news earlier that day, when the federal government rejected his application for disability assistance. That's not unusual: About 80 percent of the applicants are turned down the first time.
But it came on the heels of another devastating rejection.
Weeks earlier, an evaluator from ComCare--a firm that oversees the care of about 11,000 seriously mentally ill people in Maricopa County--also had informed Millison he wasn't disturbed enough to qualify for its help. An outside psychiatrist had urged Millison to go to ComCare for therapy.
Late on the afternoon of May 12, he returned to his room at a Tempe group home for the ex-homeless.
Millison went into his room and shut the door. He didn't appear for the nightly group dinner, which concerned the home's manager, John Todd.
Todd knocked on Millison's door. No answer. He walked in. Millison was sprawled on the floor, unconscious. Todd administered mouth-to-mouth resuscitation. Another resident called 911.
The rescue attempts failed. Jerry Millison died, Tempe police say, of an apparent drug overdose. He left no note, so it may never be certain if he committed suicide.
But Lisa Perry of Advocates for the Disabled, who had helped Millison with his application for disability aid, knows in her heart what happened.
"Mr. Millison was a decent man with big problems," Perry says. "When the systems in place to help him told him to get lost, I think he just couldn't take it anymore."
Although Arizona has poured more than $250 million through companies like ComCare since 1991, too many of the state's seriously mentally ill still can't find refuge in the system. And those able to get in often don't get the help they need.
The sophisticated professionals who run the system seem incapable of acknowledging its many obvious flaws--except to say it's underfunded. Confronted with evidence of their dysfunctional network, nearly all parties close ranks to quell dissent and defend the lucrative cottage industry.
One frustrated caseworker says the system--ComCare in particular--exhibits the afflictions of some of its clients. Her diagnosis: "Denial with acute paranoia."
"It's a ludicrous system," agrees state Representative Sue Gerard, a Phoenix Republican. "It's wasteful, and we're not even getting good patient care."
Here's how ComCare fits into Arizona's unique mental-health scheme:
The Department of Health Services contracts with ComCare--short for Community Partnership for Behavioral Health Care--and five other firms around the state. Those firms in turn contract with local counseling and other agencies, called "providers."
As of May 1, ComCare had 10,908 seriously mentally ill adults--most of them indigent--on its rolls. The nonprofit company has about 850 employees.
ComCare also provides direct services to clients, mostly case management and some medical services. DHS allocated ComCare $147 million for fiscal 1994-95, with about $75 million earmarked for care of the seriously mentally ill.
Structured like a health-maintenance organization, ComCare collects about $590 monthly from the government for each client, regardless of services provided.
If ComCare sends less than that to providers for a client's care, it gets to keep the balance. If it pays more than $590, ComCare takes the hit.
The result is a system with built-in disincentives for providing comprehensive treatment. Those disincentives could grow under the state's new contract with ComCare: DHS officials say the contract likely will allow it to become a for-profit company.
And accountability is elusive--even to those who dole out the money.
"ComCare can just continue to call the shots the way they want, spend the way they want," says state Representative Sue Grace, a Phoenix Republican. "They don't give us statistics or any kind of detailed information about what services are being delivered. They only give very raw numbers."
ComCare president Pamela Hyde would rather focus on the company's success stories. She notes that the firm's deficit--which stood at $6.3 million last July 1--is almost gone. But she quickly adds that the only way ComCare can reach its long-term goals is through more funding.
But a New Times investigation has found deep, systemic problems at ComCare--problems independent of funding shortages. A review of hundreds of documents and interviews with ComCare employees, human-rights advocates, legislators, bureaucrats and ComCare clients show that:
The State of Arizona allows ComCare to keep taxpayer dollars whether it provides meaningful--or, sometimes, any--services to clients on its rolls. The firm has received hefty financial breaks from the government to help cure its multimillion-dollar debt.
ComCare supervisors have instructed case managers to falsify client "progress notes," so as not to reflect poorly on the firm.
ComCare last year put hundreds of seriously mentally ill people in jeopardy during a power struggle with a large counseling agency. Some still aren't getting adequate services. One ComCare employee says his bosses canceled the agency's contract because the agency was becoming "another political pain."
Cozy relationships exist between ComCare and people who are supposed to be acting as watchdogs over the firm. For example, for a time in 1993, ComCare president Hyde actually shared a residential address with Linda Glenn, the court monitor whose job is to evaluate ComCare's performance.
Arizona's rules for considering grievances of the seriously mentally ill are among the nation's best. But diligent advocates inside the system have come under attack from ComCare and, at times, from the state itself.
Low pay, heavy case loads and endless paperwork have withered morale among many ComCare workers. The turnover has made continuity of care fleeting for many clients.
"How you deal with your mentally ill clients isn't nearly as important with ComCare as how you deal with your paperwork," says Bob Campbell, a case manager fired a few weeks ago after repeated run-ins with his supervisors.
"ComCare is about power. It's about image and a bank account. The rest is secondary."
Emerging From the Dark Ages
Arizona long has had one of the nation's highest per capita populations of seriously mentally ill. But until the 1990s, the state annually ranked at or near the bottom in spending on services for that population.
The dismal picture was compounded by the fact that, until a few years ago, Arizona didn't accept federal dollars to help its mentally ill.
But by the beginning of 1994, the state had surged to 17th in per capita spending.
The journey from dereliction began in 1981.
That year, the Arizona State Legislature said the seriously mentally ill have the right to receive treatment. The lawmakers didn't back up their proclamation with much funding.
Also in 1981, then-Maricopa County fiduciary Charles "Chick" Arnold filed a class-action lawsuit against the state on behalf of the seriously mentally ill. The case dragged through the courts until 1989. Then the Arizona Supreme Court upheld a lower-court ruling that ordered full funding.
"The Legislature must fund whatever programs it has required," the high court decreed. "The present system operating at the state and county levels falls far short of an adequate system. . . . Arizona has imprisoned its mentally ill in the shadows of public apathy."
It was the first time in U.S. history that a court--taking its lead from the legislative branch--had ordered such all-encompassing relief.
Negotiations between the state and the plaintiffs resulted in the "Blueprint," a document that spells out what the state must do to end the lawsuit.
The Blueprint was written directly to the seriously mentally ill, telling them, "It is important to know and understand your rights."
Linda Glenn, a nonlawyer with years of experience in the mental-health field, was hired as court monitor in May 1991. She's actually paid as a "consultant," and collected $121,000 from the state and county last year for her efforts.
Glenn's job is to oversee execution of the Blueprint.
Arizona's legislators were forced by the high court and their own 1981 proclamation to dole out far larger sums for mental-health services than ever before.
But money hasn't solved the problems. Prior to 1992, the seriously mentally ill in Maricopa County received services through three ComCarelike companies. Each had different rules, which led to confusion and difficulty for all concerned.
That year, DHS selected ComCare to run the show in Maricopa County alone. By the end of 1993, ComCare was on the brink of insolvency. ComCare's equivalent in Pima County was in equally bad shape.
An effort was afoot in the Legislature to shift responsibility for the seriously mentally ill into AHCCCS, Arizona's version of Medicaid. DHS director Jack Dillenberg backed the proposal.
Something had to give, and quickly.
Into the maelstrom stepped Pamela Hyde.
Pam Hyde to the Rescue
Pam Hyde came to Arizona from Seattle with rave reviews and a sterling rsum. She'd directed that city's Department of Housing and Human Services. Before that, she'd headed the Ohio health department.
A 1992 story in a Seattle newspaper described how Hyde, an attorney, was volunteering at a homeless shelter. Hyde told the paper her monthly stints reminded her "why I'm in the business of human services and how difficult life is for people in need."
In ComCare, Hyde found a firm with a runaway debt that had fallen from grace among many legislators. Hyde needed all the friends she could muster, and found a potent ally in Court Monitor Linda Glenn.
Given all the problems ComCare was facing, Glenn could have made Hyde's life miserable. To the contrary, Glenn made Hyde feel right at home.
Voter registration and driver's license records indicate that Hyde listed Glenn's home address as her own on December 30, 1993. Hyde purchased her own home in March 1994, according to county records.
That Glenn was comfortable enough to offer Hyde temporary shelter raises questions about Glenn's ability to act as a watchdog over the county's mental-health system--and ComCare.
Hyde declines to say whether she resided with Glenn.
"I have absolutely nothing to hide about what I did or did not do in that regard," Hyde says. "But I don't believe that my personal life, or where I live, has anything to do with this. My gut reaction is to tell you exactly what I did because there's nothing to hide. My philosophical and personal reaction is, it's none of your business."
Glenn did not return recent calls seeking comment, but told New Times weeks ago that she hadn't known Hyde before Hyde moved to Phoenix.
Hyde's first priorities included derailing the push at the Legislature to move mental-health responsibilities from the middlemen firms such as hers to AHCCCS.
Proponents of the change pointed to a federal study that revealed gaping holes in Arizona's system. "Accountability is spread among so many agencies that it is difficult to fix responsibility," it concluded. "When things go wrong, they are impossible to correct, because it is always 'someone else's responsibility.'"
One of the most persuasive witnesses for maintaining the status quo was court monitor Glenn. She also wrote a glowing early review of Pam Hyde in her May 1994 Blueprint update.
In the end, the lawmakers voted against the switch.
Victory in hand, Hyde turned her attention to the deficit and to ComCare's tattered image. By the spring of 1994, the firm had found an avenue to solidify its shaky position. It became known as "the LDI mess."
The Rise and Fall of LDI
On April 22, 1995, 24-year-old Heather hit bottom.
Her body wracked by neuromuscular disease and her mind twisted by depression, she steered her wheelchair into her kitchen, took a paring knife and cut 12 parallel grooves into the fleshy white skin on her upper right forearm.
A crisis team responded. The mutilation wasn't a suicide attempt, she told the team, it was an attempt to transfer her pain from the inside to the outside.
Heather and her husband, Lee, a 36-year-old quadriplegic, are ComCare clients. Lee is so depressed he dreads waking up in the morning. He spends most of his days in a stupor, a 98-pound man sitting naked in a wheelchair.
Until April 1994, Heather and Lee had attended weekly therapy sessions through Living Dynamics Incorporated (LDI), a large Valley agency which had a contract to serve as a ComCare provider.
But that changed when ComCare canceled its contract with LDI. The resulting upheaval meant that the couple and hundreds of other seriously mentally ill patients lost their therapists, at least temporarily. Some were placed on waiting lists and left to fend for themselves for months.
Heather and Lee had developed a strong bond with their LDI therapist, who spent an hour a week with each, and another hour providing joint marriage counseling.
The LDI therapist came to the couple's home, which Heather says made her feel safe and comfortable. Lee recalls he was happier and better able to cope. Their therapist also was a licensed nurse sensitive to their physical handicaps.
Heather says ComCare offered her reduced services at a distant counseling center six weeks after her final session with her LDI therapist. She told ComCare she needed in-home counseling because she couldn't get around. Lee also scheduled an appointment with ComCare, but was ill, and missed it.
The couple claim ComCare practically ignored them for the rest of 1994.
Lee would go without therapy for more than a year.
But Heather couldn't wait that long. In January 1995, after eight months without therapy, her anger overcame her fear of venturing out. She rode buses during a 90-minute trek to the ComCare office and demanded treatment. ComCare offered her the minimum--two hourlong therapy sessions a month--a third of what she had had under LDI.
She says it took ComCare a month to find her a therapist.
"I said that I was going to reserve my trust until I knew what ComCare was going to do with me," she says.
Her skepticism was justified. Since January, she's had only four hours of counseling--from three different therapists.
As Heather and Lee deteriorated, ComCare pocketed thousands of dollars paid by the government to treat them. It hasn't always been that way; since July 1994, the state has allowed ComCare to use money not spent for treatment to reduce its deficit. Prior to that, ComCare was required to refund money not spent on treatment.
From July through September alone, ComCare officials estimate, this new arrangement allowed the company to trim its deficit by $700,000.
The cost-cutting ploy backfired in Heather's case--she eventually required intensive treatment.
In all, she took a knife to her flesh three times, slashing her arm, knee and hand and finally puncturing a vein in her wrist. She wound up spending 22 hours at ComCare urgent-care centers and received two expensive visits from a crisis intervention team.
In late May, she was admitted to a hospital psychiatric ward for a week. She says she was hospitalized because she wouldn't promise doctors she'd stop hurting herself and she couldn't stop thinking about hurting her husband.
Lee says he plans to divorce Heather.
LDI lost its contract at a pivotal time during ComCare's history.
ComCare was hemorrhaging millions in red ink, and the Legislature was threatening to shift ComCare's duties to AHCCCS. At the same time, LDI was in a period of rapid expansion, on the verge of becoming a big enough player to challenge ComCare's supremacy.
ComCare officials say the shuttering of LDI was a prudent response to embezzlement committed by an LDI accountant. LDI also kept shoddy records, ComCare alleges.
LDI supporters contend ComCare used the embezzlement and a subsequent audit as a pretext to destroy LDI and further ComCare's own political and financial ends. They concede the embezzlement was a legitimate problem, but not one that required ComCare to drive LDI into bankruptcy.
ComCare and LDI agree on little, not even on the number of clients involved. LDI records indicate that about 750 seriously mentally ill adults lost services when ComCare canceled its contract in April 1994.
Pam Hyde claims far fewer LDI clients were affected, and that all problems were easily resolved.
"I'm not aware of anyone who was put on a waiting list," Hyde says. "We did a lot of work to make sure people were specifically transitioned."
However, Pat Pugliese, one of four state workers who advocate for the mentally ill, says she alone logged more than 50 complaints from former LDI clients who had been expelled from treatment programs.
"Most of those people didn't know what was going to happen to them," Pugliese says. "They were scared and ComCare was not doing anything to ease their minds."
Hyde also insists that ComCare case managers told every LDI client "face to face" that they'd be getting new counseling.
In fact, many people didn't learn they could no longer see their therapists until almost three weeks after ComCare canceled the agency's contract. That's when ComCare--prodded by the Arizona Center for Law in the Public Interest, which had received a flood of complaints--informed LDI's clients by letter. The letter apologized for having violated their rights to prior written notification of major service changes.
Newton Henderson is a genteel 45-year-old whose two decades in the mental-health field culminated with the founding of Living Dynamics Incorporated in 1989. The firm steadily grew into a counseling agency with 40 employees at five Valley offices.
When ComCare lowered the boom, LDI was treating more than 1,000 clients a month; its contract with ComCare brought in about $2.6 million a year.
Henderson claims his political naivet prevented him from understanding that when you deal with a monopoly like ComCare, it's best to play by its rules.
He suspects LDI crossed ComCare with plans to open all-night crisis centers around the Valley. ComCare ordered the crisis-center plan shelved, because it had similar plans.
The biggest bone of contention, however, was LDI's plan to expand dramatically into the traditionally underserved west Valley. Henderson met with west-side leaders, and even rented an office.
ComCare president Pam Hyde wrote Henderson on April 11, 1994. She said, "ComCare is not in the position to support LDI's expansion into this or into any other area," though she didn't offer specific objections.
ComCare employee Roger Nash believes he knows what those objections were. Nash, a budget analyst, gave a startling deposition last September that vividly describes the political landscape.
In his sworn statement, Nash said that Sam Ortega, ComCare's director of community programs, told him that LDI was "growing too fast, growing too big, they could become another political pain."
Nash said ComCare feared that LDI would become as powerful as Phoenix South, a provider ComCare has had difficulty controlling.
"Phoenix South pretty well gets their wishes because they're a strong agency," Nash said, "and we have hard times dealing with them sometimes because of their strength--political strength, monetary, the number of clients handled."
ComCare found a way to deal with LDI, thanks to Lynn Galloway, who had been hired in mid-1993 to do LDI's books. Galloway, owner of the accounting firm Galloway & Associates, wooed LDI's business by promising to computerize LDI's bookkeeping.
Unfortunately, Galloway had a long history of stealing from employers.
Between November 1993 and February 1994, Galloway stole $54,269 from LDI and covered it up by submitting bogus bills to ComCare. ComCare knew of irregularities in LDI's billing as early as February 1994 and sent in auditors, who failed to solve the riddle.
Even after their suspicions were aroused, ComCare officials gave Galloway access to confidential ComCare records, which he used in an unsuccessful attempt to collect on nearly $70,000 worth of phony claims within one week. After ComCare discovered Galloway's embezzlement in March 1994, Galloway destroyed the computer records.
LDI hired Jim Sell, a well-known CPA and certified fraud examiner, to reconstruct the records and to determine the extent of the fraud. Sell is a former director of regulation for the Arizona Corporation Commission, and his experience includes stints as a federal defense contract auditor and at the Arizona General Accounting Office.
During his days as a defense contract auditor, Sell had encountered some outrageous expenses, but he says nothing prepared him for what he found on this job.
"There is nobody watching the house in the health-care industry," he says. "Compared to the health-care industry, the federal government is squeaky clean."
Sell says ComCare deserves some of the blame for Galloway's scam. He says ComCare had shut off its own fraud-detection system, allowing Galloway to attempt such bold acts as billing ComCare for 20 therapy sessions a month for clients who were only authorized for two.
After Galloway's rip-off finally became apparent, ComCare launched a series of audits that Henderson assumed would retrace Galloway's steps and result in new safeguards.
But Henderson soon discovered that ComCare had another agenda: freezing out LDI.
Nine days before the audits began, someone at ComCare leaked LDI a copy of an internal memo dated March 21, 1994. In the memo, ComCare's acting director ordered the firm's case managers to "stop all referrals of ComCare clients to Living Dynamics." The case managers were also told to begin looking for "alternative placements" for clients already getting counseling through LDI.
After Henderson saw the memo, he asked Sell to monitor the audit of the agency that ComCare began on March 30, 1994.
Sell describes the ComCare audit as one of the most blatantly biased he has ever seen. Although he hadn't been aware of the political battles between LDI and ComCare, he knew something was wrong.
"The whole thing was a joke," Sell said. "They would set one criteria, then if they didn't like the results, they would change the criteria. Basically, it smelled of just trying to get something on Living Dynamics."
Sell says the audit was so slipshod, on the last day he observed members of the ComCare audit team literally flipping coins to determine whether specific bills should be paid.
Sell is convinced the audit "was an attempt just to put them [LDI] out of business. I think the audit was constructed and intended to come up with some astronomical claim against Living Dynamics. There isn't any other conclusion that could be drawn from it."
Despite Sell's claims of a prejudicial audit and that ComCare's lax accounting had helped Galloway commit crimes, ComCare branded LDI the culprit and canceled its contract.
Yet Galloway was the only person charged with a crime. After a lengthy investigation, Phoenix police and Maricopa County prosecutors listed LDI as a victim, not an accomplice to Galloway's fraud.
On October 24, 1994, Galloway pleaded guilty to felony counts of theft and criminal damage. He is serving a five-year prison sentence.
Henderson is struggling to reestablish LDI. He was able to bring the firm out of Chapter 11 in May.
A Client on Trial
In late 1993, a mentally ill, suicidal, HIV-positive man named Phil Girardin filed a complaint against ComCare.
Girardin claimed he'd been treated poorly during a crisis, that his incessant cries for help had been ignored. ComCare had provided him inconsistent or nonexistent care for months, he also alleged.
DHS' Office of Human Rights got involved after Girardin expressed dissatisfaction with ComCare's response to his grievances. Pat Pugliese, an advocate at the office, was assigned to help Girardin.
She soon discovered that the Girardin case had touched a nerve with ComCare. From its president down, the firm made it known that interference from the Office of Human Rights--created in part to make certain ComCare does its job--would not be tolerated.
DHS opened the Office of Human Rights in October 1993. One of its undertakings: Guide the seriously mentally ill through the mazelike appeals and grievances processes.
The idea is noble: "To provide independent oversight of claims of illegal, dangerous or inhumane treatment of persons receiving mental-health services and [of] legal rights violations."
But the Office of Human Rights was shackled financially from the start. The Arizona Legislature appropriated only $228,000 for its first year. DHS asked lawmakers this year to give the office a much-needed financial boost, from $228,000 to $655,000. They didn't add a cent.
"We were overworked, but we had a gung-ho attitude," says Pugliese, one of the office's four original advocates. "We thought we could make a difference, no matter the odds."
Pugliese is a diminutive single mother in her mid-30s, a feisty blend of compassion and determination; the job of advocate seemed a perfect fit.
"Most people get into social work because they care," she says. "As an ex-case manager, I had run into many folks who had a snowball's chance of being able to even ask for help when they needed it. I wanted to help those people."
Pugliese is outspoken, as Human Rights chief Bob Farmer soon learned.
"I asked Bob early on, 'How are you going to resolve the intrinsic conflict of interest of an agency [DHS] in effect policing itself?'" she says. "He said, 'Patty, there will be no conflict. We're directly under the director and we'll be given a free hand. Call it like you see it.'"
But Pugliese says Farmer soon warned her that rocking the boat could backfire on her. The notion of an advocate not rocking the boat baffled her.
"I worked with some fine people at ComCare," says Pugliese. "They have some people you can negotiate with--`Do this for my guy and I'll be out of your hair' sort of thing. Sometimes, you just have to tell your client that there's no way to get him what he wants. But there's other times when you have to fight for someone, do whatever it takes."
Phil Girardin was one of those clients.
Records show Pugliese became Girardin's advocate in late 1993. He was diagnosed as seriously mentally ill in 1992 after a suicide attempt, and his life was a disaster: Doctors had diagnosed him in 1992 as HIV-positive. His personal life was in constant turmoil.
"Talking to me at times is like talking to a really healthy vegetable," says the 28-year-old Girardin, chuckling briefly at his own plight. "But sometimes, I'm not so healthy."
November 1993 apparently was one of those times: "I had just found out I was on the edge of full-blown AIDS. I was stressed. I needed help. I left six messages for my ComCare psychiatrist, but he never called me back. I told my new case manager that I was suicidal because I was. He said I could see a psychiatrist in a week."
Official grievances often grind through the system at a snail's pace. ComCare seeks to solve client gripes internally.
Some clients are pacified; others aren't.
But it should come as no surprise that many seriously mentally ill don't have the wherewithal to make it through the arduous process alone.
If a problem isn't resolved at the ComCare level, a client may appeal to the state. Ultimately, an issue may be decided at a so-called Fair Hearing.
There, a hearing officer selected by DHS considers testimony from both sides in a quasi-trial setting. The officer then makes recommendations to the DHS director--Jack Dillenberg--who has the final say.
Phil Girardin filed his grievance with ComCare in late December 1993. In March 1994, ComCare upheld two of his three complaints, admitting it hadn't provided the proper continuity of care to Girardin.
But the firm maintained it hadn't erred during Girardin's November crisis. That infuriated Girardin. He decided to appeal ComCare's decision to the state level. Pat Pugliese warned him victory could be hollow.
But Girardin was insistent, even after his mental state took an apparent turn for the worse last June.
"The grievance process can make being mentally ill a lot worse," he says. "But I just decided it was the right thing to do."
On the morning of June 10, 1994, Girardin asked Pugliese to come to his house. Worried, she did so. He asked her to answer his phone because he didn't want to converse with a ComCare case manager who was going to call.
Pugliese relayed Girardin's message when the case manager called.
That day, Bonnie Marsh, then the director of ComCare's Grievance and Appeals section, fired off a letter to Human Rights chief Bob Farmer.
"Pat Pugliese has seriously interfered with the case and service . . . to a ComCare seriously mentally ill individual," Marsh wrote. "I request that you immediately look into this situation and provide us with a response as to what is considered appropriate advocacy . . ."
Marsh demanded an answer in a second letter to Dillenberg. Company president Pam Hyde wrote one of her own.
Pugliese refuted ComCare's allegations in a long memo to Farmer. Girardin also penned a strongly worded statement: "Pat Pugliese has never interfered in any way with my treatment at ComCare. Ms. Pugliese never said that I shouldn't have contact with ComCare. . . . She is an advocate, not a detective or dictator for me or anyone involved."
But Bob Farmer didn't defend Pugliese. She says Farmer told her she was "playing in traffic," that the system would lose a good advocate if she persisted.
Pugliese's professional reputation was on the line. Last July 15, she wrote a letter to Farmer's boss, DHS director Dillenberg.
"My supervisor has been placed under tremendous pressure attempting to provide advocacy to a dysfunctional system resistant to change," Pugliese wrote. "It appears DHS may not be supportive of protecting client rights when uncomfortable issues arise."
On July 21, Dillenberg finally responded to Pam Hyde. Briefly, he defended Pugliese: "It is my understanding that [she] acted within her authority and according to the client's request in responding to your office as the client's advocate."
But instead of chiding Hyde, Dillenberg was conciliatory. He noted that his agency's goal "is to reduce the perception that this office acts solely as adversaries to the interests you and your staff have."
(Dillenberg canceled a scheduled interview with New Times to discuss this and other issues.) On July 22, Pugliese suffered injuries in a car accident caused during a diabetes-induced blackout. She went home to recuperate after a two-week hospital stay. But she continued to help Phil Girardin.
The mentally ill usually are at a disadvantage during Fair Hearings. Because few can afford attorneys, most represent themselves. Advocates can attend hearings, but are not allowed to speak for the record and may only whisper to their clients.
ComCare, on the other hand, employs private lawyers to do its bidding against its seriously mentally ill "adversaries."
The scenario can be daunting: Mentally unstable people must face off against attorneys bent on vindicating ComCare at any cost.
Pugliese realized she needed to find an attorney for Phil Girardin, even if she had to pay for one herself.
"I got sick and tired of seeing my clients being stepped on," she says, "and I knew Phil didn't have a prayer at the hearing without a lawyer."
She convinced Scottsdale attorney Harry Howe to represent Girardin at the Fair Hearing. Howe practices mostly insurance defense, not mental-health law, but he agreed to represent Girardin. Pat Pugliese says she paid Howe $1,000 out of her own pocket.
Howe quickly realized he'd become involved in something larger than he'd expected: "I'd kept telling Phil, 'We're talking about a toothless procedure here. Don't get too worked up.' But when the hearing started, there were about 14 people from ComCare sitting there, all intense. It was peculiar. The only thing I could figure was that ComCare was trying to teach Pat and the Office of Human Rights a lesson."
ComCare retained Phoenix attorney Joseph Rocco, an experienced hand in this type of proceeding.
"These hearings consume a lot of time and money that could go to treat people in need," Rocco says. "I think if the advocate had done her job properly, we wouldn't have even been there. . . . ComCare was very concerned that they were pushing this so they could file a lawsuit."
Girardin's Fair Hearing unfolded in two sessions last August 31 and November 16. The hearing officer was Robert Hungerford Jr., a onetime judge who also hears cases for other state agencies.
Rocco conducted his examinations of Girardin and Pugliese--who attended the August session in a wheelchair--with a vengeance.
"I cannot tell you why Mr. Rocco was so personally aggressive with the client and the advocate, but he was," says hearing officer Hungerford. "It made me wonder what was going on here."
In a separate interview, Howe also commented on the vitriol.
"There was a dark side to this," Howe says. "If I didn't know better, I'd have believed there was something personal the way Joe [Rocco] went after my guy and after Pat. The mentally ill may not have any true rights, but they should have the right to tell their story without being chewed to pieces."
Rocco says he was just doing his job.
"I believe there were a number of legally acceptable and appropriate ways to attack Mr. Girardin's credibility, and I used them," he says. "I thought there was good evidence that the, quote, crisis, had been falsely reported by Mr. Girardin."
But last December 5, Hungerford sided with Phil Girardin in his findings of fact and conclusions of law.
"ComCare violated the law and rights of the appellant by failing to manage and intervene in [Girardin's] crisis in November 1993," Hungerford wrote in a nine-page decision. "ComCare [failed] to provide a continuum of care in a unified and cohesive system."
But Hungerford didn't stop there.
"ComCare's failure is greater than that. This hearing officer concludes that ComCare was not motivated to respond to [Girardin's] crisis. Even a casual review of the case manager's handling of the case would lead to this conclusion.
"It is recommended that the [DHS] Director require an audit of ComCare's performance of its obligations to the SMI [seriously mentally ill] under the law. . . . It is recommended that the Director require ComCare to provide a plan for achieving better management of the treatment of the SMI."
Director Dillenberg, the ultimate arbiter, issued his own conclusions one day later. He agreed Phil Girardin had been treated badly by ComCare in the crisis situation. But he dismissed Hungerford's suggested reforms.
"The hearing officer digressed from the issues presented to him regarding [Girardin] and sought to address perceived 'systemic' problems by offering recommended solutions," Dillenberg wrote. "This was outside of the scope of the issues and evidence presented . . ."
A week after the decision, Bob Farmer mailed Pat Pugliese a certified letter placing her on permanent disability leave. She says she had been feeling better every day.
"I believe it was retaliation for all the so-called hassles I had caused for Bob by raising questions about the office's unethical practices," Pugliese says.
(Farmer did not return phone calls from New Times.)
Bob Hungerford isn't working for DHS anymore, either. He says he hasn't gotten an assignment from the agency since the Girardin case: "The director's [Dillenberg's] decisions and his manipulations of my findings indicate that the agency was not satisfied with where I was coming from. I just called it like I saw it."
Everyone thought the Girardin case had been put to rest with Dillenberg's December 6 ruling. It resurfaced a few weeks ago.
New Times asked DHS about Girardin on the morning of May 18. That day, DHS associate director Charles "Chip" Carbone sent a letter to ComCare president Hyde. Carbone said his staff "recently" had reviewed Girardin's file, and that he had some observations.
"Documentation does reflect that Mr. Girardin attempted on six occasions to reach his case manager or psychiatrist during his reported crisis in October/November of 1994," Carbone wrote. (He was off by a year; Girardin's crises occurred in 1993.)
"There is no evidence . . . that suggests that Mr. Girardin has an Individual Service Plan (ISP) in place. Given his significant history of attempting suicide, along with the coexistence of a substance abuse problem, it would seem that Mr. Girardin would benefit from an ISP."
It would also seem to be the law.
"You have the right to a written service plan (ISP) that lists the services you need," the Blueprint says. "Those services must support your personal liberty, goals and desires."
A Layman Loses Faith
Unlike the pugnacious Pat Pugliese, Bill Adams is a most unlikely rabble-rouser.
A conservative Republican, the retired Air Force lieutenant colonel's idea of making waves is a bumper sticker deriding "Hanoi" Jane Fonda.
In 1993, he agreed to chair a state Human Rights Committee, whose nitty-gritty mission is spelled out in the Blueprint:
"To provide independent oversight of claims of illegal, dangerous or inhumane treatment of persons receiving mental-health services and [of] legal-rights violations. [Committee members] receive monthly reports on the use of seclusion and restraint from agencies in their area and review whether the use is inappropriate or illegal. They provide assistance to persons who have been determined to need special assistance."
There are three Human Rights Committees statewide, two in the Valley and one in southern Arizona. Adams says he volunteered for the committee because he has a seriously mentally ill daughter and he wanted to help the system work better.
His experience has turned him into something of a radical.
"I looked at us as being able to lend a helping hand, a positive role," says the 61-year-old Scottsdale man. "To be blunt, it hasn't gone as expected.
"No one in charge wants anyone buzzing around asking too many questions. If you listen to ComCare and the state, they'll tell you to just trust them. But what they say and what's happening in the bowels of the system are two different things."
Adams' committee had been deprived of the most basic tool it needs to do its job--names. ComCare has refused to provide the committee with the names of its clients or even the providers treating them.
"My reading of [Arizona law] and rules indicates that we are not legally required to disclose identifying information about a client," ComCare's Melody Emmert wrote to Adams last October.
Internal state documents show that an assistant attorney general, Eileen Bond, has attempted to prod DHS' Chip Carbone into resolving the issue. But, predictably, Carbone hasn't challenged ComCare's secrecy.
Without access to names and places, Adams says, it's impossible for the committees to do anything more than guess what's happening.
"We sign an oath of confidentiality, so that's just a smoke screen," says Adams. "It's so frustrating. I want ComCare to succeed, I really do. But it's hard to support an organization that tries to crush people who raise legitimate issues as if they were bugs."
Last September 27, Adams complained to Court Monitor Linda Glenn.
"My people are telling me, 'Why can't we do our jobs, Bill?'" Adams wrote. "We are confident there are widespread human-rights abuses happening daily in the system and we are frustrated because there is nothing we can do about it." Adams is still awaiting Glenn's response.
"I'm coming to the conclusion that having human-rights oversight in this system just isn't going to work," he says.
Clients' Charts Doctored
Former ComCare case manager Bob Campbell wears a pin on his lapel that says, "Mental Health Is Overrated."
ComCare thought Bob Campbell was overrated.
The firm fired him a few weeks ago--one day, coincidentally, after he first spoke with New Times.
Campbell claims he was fired in large measure in retaliation for having recently filed an official complaint of misconduct against a supervisor.
His complaint reads: "Progress notes in a client chart which was under appeal was reviewed by the Area Director. Pat Razo ordered me to remove the note I had written and rewrite as she directed. She stated I could NOT under any circumstance write a note which placed ComCare actions in a bad light. I questioned the practice of 'altering' documents in the chart and was told if I wanted to keep my job to make the changes. I wrote the note as directed and kept the original . . ."
Campbell says it wasn't the first time he'd been ordered to alter a file.
Campbell says that in February 1994, outside auditors told ComCare they'd need to see randomly selected files in a few weeks. One of the files belonged to a client Campbell had seen.
Documents obtained by New Times show that a supervisor twice ordered Campbell to re-create a "progress note" he wrote for the file because it reflected badly on another case manager--and on ComCare. "To err is human, as I well know," says Campbell. "But ComCare takes it one step further. The bosses seem to think that to cover up is human, too. The auditors don't see problems because they're not seeing true charts--they're seeing spit-and-polish charts."
Campbell was the only current or former ComCare case manager who agreed to be identified. But New Times asked two current case managers about the alteration of client records, which is illegal. Both said it doesn't happen very often--but not because it's a crime.
"Most of us know better than to put anything critical about ComCare on a document," said one of the case managers. "That's just the way we do business. We're kind of paranoid. Bob Campbell probably was on the money. But he should have known better."
ComCare says Campbell has no credibility.
"Bob was fired because he did many things inappropriately," says ComCare president Pam Hyde, who insists it is Campbell, not ComCare, who has broken the law.
"If he gave you information that came from a client file, he has violated the law," Hyde says. "And that is precisely the kind of thing that he was fired for."
In February 1994, according to records provided for New Times by Campbell, a supervisor asked Campbell and another case manager to drive a seriously mentally ill client home. The client, whose name is blacked out on the records, had told ComCare that she had weapons inside her home.
Neither Campbell nor the other case manager knew the client, so he reviewed the chart for some background. He found little. The case manager's previous entry was four months old. The chart failed to mention that the woman had been hospitalized just ten days earlier.
Campbell updated the chart, noting that the client had complained to him repeatedly about her case manager's lack of attention: "Client stated that she had requested chemical dependency counseling, but no current records of any request and/or referral were found."
He dated the progress note, "2-22-94." But he says he actually wrote it in early March.
"I actually wrote the first note, my real note, on February 22," Campbell says. "But a few weeks later, my team leader told me to do a rewrite because the auditors had picked it at random to study. In other words, creative writing was to ensue."
Campbell apparently wasn't creative enough because his supervisor wrote him a note ordering him to try again.
Pam Hyde insists the rewrite order was legitimate and wasn't intended to skew an auditor's findings.
"That was a legitimate concern, and there are ways to bring it up," Hyde says, "[but] it's inappropriate to put certain things in records. Bob put his opinions about another staff member in the record. He was asked to remove it and focus on the client."
Campbell says he also was asked last year to redo another ComCare client's file, months after the fact. The client was Debbie Reagan, a seriously mentally ill woman whose grievances against the firm were about to be heard by DHS.
"No one is asked to redo a file that's going to stay internal," Campbell says. "But when an auditor is coming in or a case may go to a Fair Hearing, the supervisors look at the files with a magnifying glass."
Reagan's story is a tragic one, even by the standards of the seriously mentally ill. She's now 37, and court records and interviews indicate she's a manic-depressive ex-hooker who has been strung out on heroin for much of her adult life.
Campbell first met Reagan in early 1991, when he was assigned as her case manager. Reagan was about to be released from prison, where she had served nearly three years on a drug-related conviction.
"I wanted to have a chance at making it when I got out," Reagan says, "so I tried to get help before they let me go."
After Reagan's release, Campbell referred her to Living Dynamics Incorporated, one of his company's providers.
"It made a big difference to me," Reagan told a judge last December. "Everything seemed like it was gonna work out. I knew I would be in therapy a lot longer than I would be on parole, but that was okay."
Unfortunately, Reagan was one of the clients who lost services when ComCare canceled LDI's contract.
"LDI ran into a problem," Reagan told the judge. ". . . They had no money to pay the therapist, so I lost mine. Then I was all alone."
Her probation officer concurs that Reagan was doing well on parole--staying off drugs and alcohol, keeping out of trouble and religiously taking her antidepression medicine. She was living alone in a Glendale apartment, on a waiting list for semisupervised housing.
"[Debbie] had been seeing a therapist on a weekly basis to discuss a wide range of issues, from daily life problems to substance abuse," the probation officer wrote last December. "Unfortunately, the counseling agency's contract with [ComCare] ended and the defendant was abruptly without a therapist."
Campbell says he attempted to place Reagan with other counseling agencies, but was thwarted.
"Things were so jammed up because of the LDI mess that some providers weren't even putting clients on waiting lists," Campbell says. "Debbie couldn't understand why all this was happening, and I had a hard time explaining it to her."
Campbell's difficulty becomes apparent in an April 25, 1994, progress note about Reagan: "Client [called] to complain about services from Living Dynamics being dropped. ComCare has dropped all services provided by Living Dynamics, with no explanation given to either clients or ComCare staff."
Campbell's case file indicates Reagan missed several meetings with him and other ComCare personnel to discuss things. He also noted in a May 17 entry, "Client has already contacted Arizona Center [for Law in the Public Interest] and client advocate. Has scheduled meeting, which was canceled due to unavailability of Area Director."
Campbell says Area Director Pat Razo then instructed him to rewrite the file, which he did.
He toned down his comments about LDI's sudden demise to say, "Client had already heard parts of a story about why services were being dropped. Client was informed by case manager that the matter was an administrative decision by ComCare."
Campbell adds that Razo specifically told him to remove his notation, "Meeting [with Reagan] was canceled due to unavailability of Area Director." The new entry read: "Has scheduled a meeting, which was canceled."
At the same time, Campbell says, Razo ordered him to retain the references to Reagan missing appointments with ComCare.
"My note about Pat Razo not being available wasn't a big deal," Campbell says. "She's a busy person, and canceling one meeting isn't the end of the world. But it's indicative of how much into spin control we are, in public and private."
ComCare's Pam Hyde counters that she's confident that no one--other than Campbell--is guilty of wrongdoing in the Reagan affair. Without her regular, intensive counseling routine, Debbie Reagan began to slide. Last July, police arrested her for stealing some things from a neighbor. As a one-time loser on parole, there was no hope of leniency.
Last December 2, a judge sentenced Reagan to four years in the Arizona Department of Corrections. She won't be eligible for parole until mid-1996.
"Listen, I'm the one that screwed up," Reagan says in a phone interview from prison, "but I was kicking butt, trying the hardest I've ever tried to do good. Losing my therapist was like a punch in the face. ComCare was getting paid to help me, but they didn't give a shit about me."
Reagan's grievance about the way ComCare treated her is still inching its way through the system.
Bob Campbell is looking for a new job. He says he spoke to an FBI agent last week about ComCare. He went to the feds, he says, because there was nowhere else to turn.
"We've got things nailed in our area of the world," Campbell says, forgetting for a moment that he's no longer part of the "we."
Next week: The Office of the Court Monitor.
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