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Freedom From Harm

Incidents at LifeQuest in Palmer, NE (Update)

Palmer, Nebraska

UPDATE: LR 296 FINAL REPORT

On December 15, 2018, the State-Licensed Care Facilities Oversight Committee submitted their final report pursuant to LR 296. According to the report, the seven members of the Committee met six times, visited 12 assisted living facilities, and reviewed information and documentation from the Department of Health and Human Services. The Committee addressed five areas in which 20 recommendations were made to improve the current state of Nebraska's state-licensed care facilities. These recommendations are summarized below. For more details, read the full version of the LR 296 Final Report. 

 

ACTIONS BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES:

  • Increase number of facility inspectors to allow for sufficient inspections and keep facilities aware of the likelihood of random investigations
  • Designate separate staff for the investigation of complaints and for carrying out routine inspections
  • Conduct drop-in investigations more frequently to supplement the comprehensive five-year inspections
  • Require facilities to self-report incidents or rule violations
  • Modify current data reporting capability or utilize a more efficient data system
  • Respond to legislative requests for data and information in a more timely, forthcoming manner
  • Establish protocol to facilitate communication between DHHS Regulations and Licensure and first responders so concerns can be shared in a more timely manner
  • Develop a contingency plan of action in the event of a facility closure to prevent residents from becoming homeless

REIMBURSEMENT AND FUNDING

  • Establish a special provider rate for assisted living facilities serving large populations of residents with serious mental illness
  • Undertake a study of how effectively and equitably current funds for behavioral health services are being used and pursue new funding streams
  • Research best practices used by other states to provide housing and supportive services for people with serious mental illness

RESIDENTIAL ALTERNATIVES

  • Develop secure crisis residential facilities across the state for short-term placement of people in psychiatric crisis
  • Develop long-term, semi-permanent group homes for individuals with serious mental illness who need a level of care between that provided in a secure residential setting and independent community living
  • Develop an array of short-term and long-term transitional housing alternatives to facilitate transition into more permanent housing
  • Increase availability of permanent supportive housing in Nebraska following recommendations of the Technical Assistance Collaborative (TAC)
  • DHHS should provide regular updates to the committee on its progress in implementing TAC's recommendations

GREATER INVOLVEMENT OF THE BEHAVIORAL HEALTH REGIONS

  • Behavioral health regions should take on a greater role in serving individuals with serious mental illness residing in assisted living facilities

LEGISLATIVE ACTIONS

  • Establish a broad-based permanent legislative behavioral health task force to identify service needs and monitor behavioral health services in the state
  • The LR 296 committee should be reestablished in 2019 with a final report due to the Legislature in December 2019

How We Got Here:

In the summer of 2017, concerns arose concerning the health and safety of residents living at the Life Quest facility at the Coolidge Center in Palmer, Nebraska and Life Quest at Bel Amis in Blue Hill.  Both facilities were licensed as mental health centers. Inspections of the facilities were done by Division of Public Health and both facilities failed to meet the standards of the Department of Health and Human Services. The Blue Hill facility failed to comply with regulations on multiple occasions dating back to 2012. Conditions and lack of treatment become more visible to the public with the death of a female veteran at Palmer on September 3, 2017.

Timeline:

  • 7/21/17:  Division of Public Health conducts inspection at Life Quest-Palmer and issues an 81-page report documenting multiple violations.
  • 9/3/17:  U.S. military veteran dies at Life Quest-Palmer.  Following her death, a law enforcement investigation of the facility is launched.
  • 9/22/17:  The Division of Public Health issues an investigative report into the resident's death.
  • 10/5/17:  The Division revokes Life Quest-Palmer's license to operate as a mental health center and concurrently conducts an inspection of Life Quest-Blue Hill, issuing a 42-page report documenting multiple violations. 
  • 10/20/17:  Effective date of  Life Quest-Palmer's license revocation.  Notice of Disciplinary Action concurrently filed against Life Quest-Blue Hill
  • 1/18/2018: Senator Lynne Walz of Fremont introduces LB 1093 to establish the office of the Inspector General of Nebraska Public Health within the Office of Public Counsel in order to conduct reviews of state-licensed healthcare facilities.
  • 1/23/18:  LR 296 is introduced by Senator Walz.  The resolution would require the Executive Board of the Legislative Council to appoint a special committee known as the State-Licensed Care Facilities Investigative Committee of the Legislature to look into conditions at the facilities.
  • 2/21/18:  LR 296 goes to hearing in front of the Executive Board of the Legislature.  Sen. Walz states that "Nebraskans who struggle with persistent and severe mental illness deserve better treatment than they are receiving from facilities that are licensed by the state Department of Health and Human Services." 
  • 2/26/18: Life Quest-Blue Hill closes its doors. 
  • 4/11/18:  LR 296 is adopted by the Legislature on a vote of 26-13, creating the State-Licensed Care Facilities Oversight Committee.
  • 4/18/18:  Sens. Curt Friesen, Steve Halloran, Lou Ann Linehan, Dan Quick, Theresa Thibodeau, Lynne Walz and Anna Wishart are appointed to serve on the Committee.  LB 1093 is indefinitely postponed.

Disability Rights Nebraska continues to monitor the placement of the people who lived in both facilities. 

Disability Rights Nebraska responded to news of the closure of the Palmer facility with a letter to Courtney Phillips, CEO of the Department of Health and Human Services for the State of Nebraska expressing grave concern about the deaths of two residents and the violations at the facility.

The letter can also be accessed here.

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