When 23-year old Cody Arbuckle died after 19 days in a Las Vegas home licensed for drug and alcohol treatment, it fell on his mother, Kathy Deem, to request a state inspection of the facility, owned by Solutions Recovery.

State officials, who never visited the home where Arbuckle died as part of their investigation, say by the time they responded to Deem’s request, patients and staff who may have had information had moved on.

An investigation by the Current identified at least four deaths at Solutions’ facilities since 2016, and a startling lack of oversight of deaths in health facilities regulated by the state.

Senate Bill 457 would expand the reporting requirements to a “facility for the dependent or home operated by a provider of community based living arrangement services,” including residential rehabs.

“I think that’s a great idea. Laws need to be changed there in many ways,” says Deem, who resides in Indiana. “If I had known more, I would have never, ever sent Cody there. They should not be able to cover this up and keep it from the public.”

In Nevada, only medical hospitals are required to report sentinel events, defined as unexpected injuries or deaths, to the state. Health care facilities, such as homes for the mentally ill, residential substance abuse treatment and sober homes, are not required to report client deaths to the state.

But sentinel event reporting, though an improvement, does not offer the transparency Deem and patient advocates say are necessary for informed decision-making by potential clients.

“In concept, we fully support mandatory reporting and investigation of sentinel events that take place in addiction and/or mental health facilities as identified in this bill,” says Monica Chairez of the Recovery PAC. “We believe in mandatory reporting and that the information should be available.”

Sentinel event reports are released annually by the state. With the exception of a map depicting the location of sentinel events, facilities are not identified and little information is readily available to the public.

“Families affected by addiction and/or mental health conditions have the right to this transparency when making the difficult decision as to where they place their loved ones,” says Chairez.

Of the 7,977 patients discharged from substance abuse treatment in Nevada in 2016, almost half — 49 percent — were in long-term residential treatment, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) of the federal Department of Health and Human Services. That’s the highest share in the nation. Alabama and Wyoming have the next highest at 28 percent.

Some 25 million Americans over the age of 12 are addicted to drugs or alcohol, according to the National Institutes of Health. In 2016, about 1.5 million sought treatment from a publicly funded rehab facility. A fraction of those patients — 3,514 or .2 percent — died while in treatment. That’s twice the death rate of publicly funded rehab facilities in Nevada, where just under 8,000 patients sought help in 2016, and eight patients are known to have died while in treatment.

But in Nevada and some other states, the number of deaths at non-medical private facilities, where private insurance picks up the tab or patients pay cash, is unknown because of gaps in reporting requirements that allow residential treatment and other deaths to go unreported.

Solution Recovery’s parent company, American Addiction Centers (AAC), is publicly traded and struggling financially.

In December, the company confirmed it was laying off employees in Las Vegas and closing some facilities in other markets. The company did not respond to requests for comment regarding its Las Vegas centers.

“It sounds like they’re just renaming it,” says Kathy Deem, who is suing AAC for her son’s alleged wrongful death.

In SEC filings late last year, AAC blamed a change in Google’s algorithm for a drop in admissions since last summer.

About the same time of the reported drop in admissions, in July 2018, AAC’s CEO, Michael Cartwright, told a congressional subcommittee the company had just abandoned the practice of paying intake personnel on a commission.

Sentinel events are often the result of medical errors, which kill thousands of people a year. But with medical professionals historically reticent to report errors, nobody really knows how many.

Estimates in America vary from 75,000 to 400,000 a year, which would make preventable medical errors the third leading cause of death, behind heart disease and cancer.

Some states collect information from just hospitals, while others include reporting from acute care facilities. Additionally, some accrediting organizations, such as the Joint Commission, make reporting of sentinel events voluntary among its member organizations.

The state legislation also calls for the Division of Public and Behavioral Health to “compile and post on an Internet website maintained by the Division information concerning the licensing status and quality of (1) facilities for the treatment of abuse of alcohol or drugs; (2) halfway houses for recovering alcohol and drug abusers; (3) medical facilities that provide treatment for the abuse of alcohol or drugs; and (4) unlicensed programs for the treatment of alcohol or drugs.”

An official with the Division says she doesn’t know how many facilities would be added to the reporting requirements under the proposed legislation. The division estimates the measure would have no fiscal impact.