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. . . .
"So we're to believe that the boarding home was the middleman, playing doctor and banker to Donald day by day? I'd like to see one canceled check with Donald's signature on it. Who do they think they are kidding?"
During a hearing recess, Donald's sister Mary Howard asked his attorney, Connie Leon, if AVSC would be compelled to explain why it paid thousands of dollars to boarding homes while Donald was in jail or mental hospitals.
Leon explained she had been unable to get Donald's jail records because, she claimed, the "jail computer" only goes back for six months. But New Times easily uncovered the dates of Donald's incarceration at the county jail and at government psychiatric wards for eight years preceding his death.
Leon then conducted a tepid cross-examination of Cooper, failing to question the AVSC official on numerous impeachable areas. For example, Leon barely touched on the key question of Donald's whereabouts from the summer of 1995 to early 1996.
During her direct examination, Cooper had testified that Donald lived at Burkeshire from August until November 1995. Then, she said, he moved directly to the Crystal Lodge, a supervisory care home where he would stay until January 1996.
In response to a question from Colosi, Cooper said AVSC paid Crystal Lodge $950 for Donald's November 1995 room and board.
"Would you expect if Donald left at any time [during the month], that AVSC would pay for the full month?" Colosi asked. "If a client is there for one day, no," Cooper replied. "If he wasn't there for the majority of November, we would ask for a refund."
However, records show Donald spent at least 20 days of that month in custody--and AVSC never asked for a refund.
In December 1995, Cooper testified, Donald moved back and forth from Burkeshire to Crystal Lodge at no charge to his account.
But court, police, jail and county hospital records--records that inexplicably weren't presented for consideration during the hearing--refute Cooper's account.
At a December 6, 1995, hearing attended by Ellison's attorney, Connie Leon, a judge ruled that Donald was persistently and acutely disabled and was to undergo inpatient treatment.
Far from getting free lodging at the Burkeshire and Crystal Lodge, as Cooper averred, Donald spent the rest of December and the first week of January 1996 at the Arizona State Hospital.
Cooper then testified that Donald had moved to La Fontenelle care home, where, she claimed, he stayed for about two months before he was committed to the Arizona State Hospital. (He actually was committed to Maricopa Medical Center.)
Colosi asked her if AVSC had reinvestigated Donald's whereabouts during this time or any other time.
"There was no need to further investigate," Cooper replied, claiming the agency always had been in constant contact with Donald.
But records indicate that from January 7 until July 24--the date of his fateful release from the county psych ward--Donald was in custody for all but eight days, during which time he resided at La Fontenelle.
AVSC's own records show it paid La Fontenelle $528 for three weeks of room and board in January, then $650 for February. AVSC got no refunds from La Fontenelle for the more than six weeks that Donald did not stay there.
Cooper testified La Fontenelle was "holding its place" for Donald, in the event he was released from custody. But a La Fontenelle official says that's not how he recalls it.
"[AVSC] told us to hold Donald's bed until the court matters were decided," says George Potvin, La Fontenelle's assistant administrator. "At the end of February, we elected to terminate his space. Quite honestly, we've been very leery of the way AVSC handles the funds. It's not exactly by the book. We could have just continued to collect, of course, but we called them and said, 'It's been long enough.'"
Mary Howard left the courtroom immediately after the hearing, without waiting to talk to Connie Leon. (Leon did not return several New Times calls requesting comment about her apparent lack of prehearing preparation.)
"This was a phony deal," Howard said tersely. "AVSC would go for weeks not knowing where Donald was. He hated them and they couldn't have cared less about him. But what can you expect from a system that would have allowed all this to happen in the first place?"
Colosi took the matter under advisement, noting that he would base his decision solely on the testimony given at the hearing.
