Arizona Daily Star (Tucson)
March 31, 2007 Saturday
Gov. last to know in veterans home problem
PHOENIX – Gov. Janet Napolitano’s top aides knew about problems at the state veterans home for more than a month and told the governor only after a media inquiry.
Susan Gerard, director of the Arizona Department of Health Services, said in an interview Friday that she told the governor’s co-chief of staff, Alan Stephens, about the problems on Feb. 9.
But it wasn’t until last Friday – March 23 – that the governor says she found out about the review showing patient neglect at the state’s sole facility for elderly veterans.
It was only after a Phoenix newspaper reporter requested the report from Health Services that word reached Napolitano, six weeks after her staff knew of the situation and more than a week after a report had been hand-delivered to her office.
Those involved say they felt things were under control and they were following protocol by not going to Napolitano. Others see the situation as a communication breakdown.
Gerard and Stephens’ conversation on Feb. 9 followed an unannounced routine inspection of the Phoenix veterans home by Health Services earlier that day.
Inspectors found many violations, including: patients left unsupervised while smoking, burning holes in their clothes; a patient covered in urine who had to drag herself down a hallway because no one would answer her call button; and a patient left in soiled bedclothes for nearly an hour.
The review has become a major issue for the administration, leading to the firings and resignations of several people involved in the management of the home. Both the governor and legislators have called for investigations.
And earlier this week, a deputy chief of staff for the governor – one of the first to find out about the review – said the office is looking into why the governor wasn’t told sooner.
The director of Veteran Affairs, Patrick Chorpenning, resigned on Tuesday. He has been criticized for not telling the administration about the review himself.
The Star obtained e-mail through a public-records request that indicate Napolitano’s staff was initially alarmed by the reported conditions at the home, and Gerard discussed whether the media would find out about the review.
Jeanine L’Ecuyer, a deputy chief of staff and the governor’s spokeswoman, and January Contreras, a policy adviser, found out about the review on Feb. 10 – a day after Stephens.
In e-mail among L’Ecuyer, Contreras, Stephens and Gerard, L’Ecuyer wrote: “Holy cow. We need data ASAP on the State Veterans Home. What exactly happened? Where are these people going?”
Contreras wrote: “(Health Services) staff is at the facility, they work with the home to create a plan for how to fix the immediate problems … (they) won’t leave until they feel the residents are safe.”
Gerard responded, saying her media spokesman said “unless there was a 911 call or a ‘tip’ this wouldn’t generate press. He would get a call if press was involved. This was a routine survey.”
“My response was, basically, panic,” L’Ecuyer said in an interview. But by the following Monday, L’Ecuyer said she and Stephens were assured by Gerard that any “immediate danger had passed.”
“We rely on the expertise of the professionals who run these state agencies,” L’Ecuyer said. “We have to rely on them; these are very large agencies.”
Gerard, who reports to Stephens, said she didn’t think of telling the governor because “that’s not my job. I tell Alan or other people, and they make that determination. I don’t usually speak directly to the governor.” But she said, at that point, “the facility was being very cooperative. I felt confident we were going to stabilize the situation.”
Also, Stephens asked Gerard to call Chorpenning, who she says never called her back.
In early March, there were “a few” conversations about the status of the home, L’Ecuyer said, and everyone felt the facility was under control.
By mid-March, a month after the first conversation, the report was completed, and Gerard says a final copy was hand-delivered to Napolitano’s staff.
L’Ecuyer says it was given to Contreras on March 16 or 19 and was not the final copy, only a draft – a point Gerard disputes. L’Ecuyer says Contreras and Stephens discussed the report, but still found no reason to notify the governor of the findings.
On Thursday, March 22, a Phoenix newspaper reporter requested a copy of the report, and Health Services contacted the Governor’s Office to notify them of the request. The following day, Napolitano was told about conditions, L’Ecuyer said.
“When I look back at the way this was handled, obviously they didn’t understand the process, the magnitude of the problem,” she said. “Obviously I did not make that clear to them.”
Napolitano was in Washington, D.C., on Friday. Napolitano and Stephens were not made available for comment.
Republican lawmakers wasted no time criticizing the situation.
“What kind of operation is this?” asked Rep. Jonathan Paton, a Tucson Republican and member of the legislative committee investigating. “They seem more interested in responding to a news story than fixing the problems when they occurred.”
“Clearly there’s a management problem in her Cabinet, and veterans are paying the price for that,” Paton said.
But L’Ecuyer said all indications are that during the six weeks between staff finding out about the review and Napolitano learning of it, conditions at the home were under control and residents were in a safe setting. That led Paton to question why, if that was the case, Napolitano stressed the need for immediate action early this week.