The cases of abuse in Utah long-term care facilities detailed in a new report from a Utah-based advocacy agency for people with disabilities are “appalling and deeply troubling,” Utah Health Care Association/Utah Center for Assisted Living President and CEO Allison Spangler told McKnight’s Senior Living. But they also point to a need for survey and enforcement system reforms, she said.
“The current survey and enforcement system treats long-term care providers like they are all bad actors, and as a result, the system has been shown to be inconsistent and ineffective,” Spangler said.
The association supports “oversight, transparency and accountability,” she said, “but a purely punitive approach that treats all long-term care providers like they are bad actors will not improve care — it hasn’t for decades. We must foster an approach where providers and regulators have a shared responsibility to do what is best for the residents, and effectively remedy identified issues.”
The 11-page report from the Disability Law Center, a private, nonprofit organization that advocates for state residents with disabilities, is titled “The License to Mismanage: Investigating Utah’s Troubled Long Term Care System” and was released on Monday. It maintains that state regulators in Utah “ineffectively protect individuals with disabilities in long term care facilities” and “seem to operate in a culture of protecting businesses rather than protecting people.” The report also accuses licensing agencies and other state agencies of levying insubstantial fines and prioritizing keeping “troubled” facilities open.
“With the threats long term care residents face from abuse, neglect and lack of treatment and the potential loss of federal funding, it is imperative that the state of Utah act now to ensure appropriate oversight of long-term care facilities,” the report states. “The DLC recommends that state agencies and policy makers work with consumers and other advocates to enhance regulations, assure quality oversight, and to build a system that ensures safe and effective care for people with disabilities in the state of Utah.”
Highlighted in the document is the experience of 48-year-old Chien Nguyen, who lived in an unlicensed facility, Evergreen Place, that was shut down in January 2022 due to “deplorable conditions.”
“At the time of the shutdown, state and local agencies were aware of problems at Evergreen,” according to the report. “As documented in an affidavit by law enforcement, the owner of the boarding house said ‘he had applied for an assisted living license, but “due to some background issues” never heard back from the state health department, so he opened his facility as a “group home” instead.’ ”
After Evergreen Place was shut down, Nguyen was transferred to Hidden Hollow, an intermediate care center for people with intellectual disabilities. He had diagnoses of schizophrenia and schizoaffective disorder and “was consistently experiencing suicidal ideation,” according to the report, which said that the placement “may not have been consistent with his primary diagnosis.”
When Nguyen tried to take his own life by lying down on a busy road, the report said, the facility’s administrator “pulled Chien out of the street but apparently did not notify facility management of this suicide attempt, did not inform the incoming night shift staff … or take any increased precautions to monitor Chien at that time. Chien’s brother Nick visited that very evening and was also not told that his brother had had a suicide attempt earlier that day, but Chien let him know that he had not been receiving his medications.” Nguyen died by suicide the next day.
“We offer our deepest sympathy to the families who have experienced such a heartbreaking tragedy,” UHCA/UCAL’s Spangler said. “Even one instance of abuse is too many, and the safety of residents and staff is the top priority for long-term care providers in Utah.”
The report comes days after the state attorney general’s office charged workers at Hidden Hollow with reckless aggravated abuse of a vulnerable adult and two former managers at Evergreen Place with neglect, unsafe and unsanitary living conditions, financial exploitation and licensing violations.
“While we were pleased to see that State Attorneys General from the Medicaid Fraud and Control Unit brought charges against individuals from both facilities, Utah must be proactive in its efforts to prevent harms like this from ever occurring again and take steps to provide appropriate oversight,” the Disability Law Center said in a statement. “We urge State Officials to do better, and we encourage you to join this call.”
In a statement to McKnight’s Senior Living, the Utah Assisted Living Association said that the primary goal of its senior living provider members “is providing high-quality care and advocating on behalf of seniors” and that members “have an ongoing commitment to protect the rights and safety of senior living residents.”
“We are saddened by the events that led up to the death of Mr. Nguyen. Our hearts go out to his family,” UALA said, adding that “neither of the facilities involved were UALA members.”
Tuesday, a day after the report’s release, the Utah Department of Health and Human Services responded to the report, saying that it was “a hard read” but that “we will own the challenge before us.”
With changes made at the department within the past year in the areas of licensing oversight, penalties and sanctions, “we expect that Utahns in any type of care facility will have better protections,” the department said. And starting July 1, the licensing office will use civil money penalties for providers who don’t comply with licensing rules, the department said.
“The money from those fines can be used by DHHS to train employees and providers, help people find a new place for clients to receive services if the facility serving them shuts down, and improve data systems,” the department said. “This helps increase the quality and continuity of services for the people we serve.”
The compliance history of licensed human services providers this year also has been put online and is searchable, said the department, which has plans to do the same for healthcare licensees. The department also said it is seeking input from providers on rule changes, providing education for providers who apply to be licensed, and evaluating the regulatory framework that governs licensing.
UALA told McKnight’s Senior Living that the group is “committed to assisting regulatory bodies in defining standards as they apply to the management of senior housing and seeing those standards met.”
“Overall, our members’ experience regarding State oversight has been consistent. They are surveyed at regular intervals and subject to unannounced visits,” the association said. “In the spirit of continuous improvement, we would also stand behind any improvement to oversight that can create better protections for older adults and the providers who care for them.”
UHCA/UCAL’s Spangler said that the “purpose behind government oversight of long-term care facilities is to ensure the safety and well-being of our residents, and long-term care providers share in that purpose.”
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