Loy’s death marked a failure of the program’s leadership, according to investigative records obtained by The Atlanta Journal-Constitution. The state found that Highland Rivers was neglectful, failing to perform basic procedures that could have prevented the overdose.

“She was let down, and so was her family,” said Josh Ellis, her brother. “She had a dream. She had plans.”

The state investigation by the Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) found staff was not properly trained and did not have adequate supervision — Loy was not fully searched and did not receive the required drug test upon her return to the facility from grocery shopping.

After the death investigation, the state issued Highland Rivers a corrective action plan, outlining program improvements that must be made.

Loy’s death represented the culmination of Highland Rivers leadership neglecting the programs it runs in Cobb County, the agency’s current and former employees say. Three whistleblowers reported allegations of gross mismanagement to DBHDD, prompting an investigative audit conducted this year.

The whistleblowers say those who are supposed to provide oversight — the state, the Highland Rivers board of directors, and CEO Melanie Dallas — have failed to address the mismanagement and have all blamed each other for the problems.

“How many corrective action plans are you going to go through before you realize that this is broken, or this isn’t working, or there’s willful neglect here? Because yeah, somebody died at Mothers Making a Change, and they got a corrective action plan for it, but the problem isn’t solved,” one of the whistleblowers said.

Community service boards like Highland Rivers are quasi-governmental agencies contracted by the state’s DBHDD to provide services to some of society’s most vulnerable people suffering from mental illnesses and disabilities, and who don’t have insurance or are on Medicare or Medicaid. The agencies receive federal, state and local funding.

Auditors found a pattern of issues that have led to the deterioration of services, then said the state does not have jurisdiction over half of the audit’s 10 findings and left them out of the corrective action plan. It is unclear where the state’s authority ends and the board’s authority begins, creating a gap in oversight, whistleblowers say.

Audit drafts reviewed by the AJC show DBHDD scaled back its final report after Dallas complained that the state overstepped its authority.

Highland Rivers is not the only agency facing similar issues in Georgia; in 2023, the state ranked 49 out of 50 in the U.S. for access to mental health care, according to Mental Health America.

The AJC interviewed all three whistleblowers, four former staff members and three current employees who asked not to be named in this story because they fear retaliation.

The Cobb programs used to be run by the Cobb Community Services Board (CSB) before it consolidated in 2022 with Highland Rivers, which also operates in 12 rural Northwest Georgia counties and is now the largest CSB in the state.

Dallas said the Cobb CSB had problems before she took over, and the state failed to provide proper oversight. Consolidating during the pandemic also proved difficult, she said.

In the final report, DBHDD referenced severe staffing challenges health care agencies face across the state in the wake of the pandemic.

But the audit drafts and the whistleblowers say Highland Rivers leadership contributed significantly to the deterioration of its programs.

Mothers Making a Change

The Mothers Making a Change program was founded in 1993 and was once the crown jewel in the Cobb community services arsenal for its work in rehabilitating low-income mothers with substance use disorders.

It is Cobb County’s only state-run women’s treatment and recovery support program, and it’s unique because children under 13 can live with their mothers in apartments. These types of programs across the state also provide wrap-around services to pregnant women and mothers, including counseling, therapeutic child care and vocational training.

Today, Mothers Making a Change is in dire straits: Some of the apartments have had visible mold, rodents, bee and roach infestations, and ceilings caving in, the audit found.

Current and former employees said Highland Rivers’ leadership has done little to address the deteriorating conditions.

The apartments have been substandard for a long time, Dallas said, adding that she requested additional funding from Cobb officials and DBHDD. But a DBHDD spokesperson, Cobb Chairwoman Lisa Cupid and three state lawmakers from Cobb each said they never received a request.

“We did make it clear what our limitations are, we made our partners aware of the need, and I can’t control whether they consider that a formal request or not,” Dallas said after the AJC requested documentation of her request. She was unable to provide any.

Dallas said the program’s location in an apartment complex makes it difficult for staff to search clients before they go to their rooms. But the state’s investigation found that apartment keys are kept in the office, and staff searched Loy’s groceries, but failed to search her person.

Staffing at Mothers Making a Change is another huge problem, according to the audit.

Staff must work hundreds of hours of overtime to fill shifts, and beds have been taken offline because of shortages, employees said.

Dallas started a capital campaign to raise money for the program last year and said close to $1 million has been committed from several donors. The goal, she said, is to raise about $4 million for a facility to house the program. If unsuccessful, Dallas said she may have to close or move the program.

“I don’t know if I can keep it in Cobb,” Dallas said. “Because we’re not getting the support in Cobb to be able to help support these women.”

A staffing crisis

Staffing issues are rampant throughout other programs as well, the audit found.

The shortages hit Cobb’s programs particularly hard due to the higher cost of living compared to the rural counties in Highland Rivers’ service area, current employees said.

Five programs in Cobb have closed, and those still operating serve significantly fewer people than before consolidation.

The individuals served in Cobb County decreased by 15% under Highland Rivers in 2022, the audit found. The agency’s 2023 annual report shows that it has gone down to 3,123 Cobb residents served — another decrease of 20%.

Yet the number of people needing access to these programs has increased: Officials say Georgia will need five more behavioral health crisis centers by 2025, the AJC previously reported. Many of the available beds in crisis centers can’t be used because of a lack of staff, which heavily impedes the state’s ability to provide emergency mental health care to those who need it.

In some parts of the state, as many as 20% to 50% of beds in crisis facilities are empty, the AJC previously reported.

Early drafts of the audit explicitly blame the staffing shortages on Highland Rivers management.

Highland Rivers had 315 vacancies out of 1,076 positions as of Oct. 23, with 137 of those related to programs in Cobb County, including programs that closed due to lack of staff. Of all the agency’s vacancies, 43% are in Cobb.

The audit reviewed two months of payroll invoices and found Highland Rivers paid its staffing agency $1.1 million, including $252,000 in service fees, which the auditor wrote “appears to be a questionable business decision.”

Auditor Kenneth Ward removed that section from the final audit because the state has no authority over the use of staffing agencies — the Highland Rivers Board of Directors does, he wrote in the final version. Highland Rivers board members are appointed by commissioners from each county in which it operates.

Highland Rivers’ Board Chairman Pete Quinones said in October that he had not fully read the audit, and that he supported Dallas. In a later interview, after reading the audit, Quinones said he plans to be “more hands-on, a little more suspect, and a little more thorough” with Dallas.

He said the board provides governance but does not oversee operations.

“If the board of directors has the ability to decide on things like (staffing), she’s just acting on her own,” Quinones said. “Because nobody on the board has ever, since I’ve been on there, operationally told her anything.

“I wouldn’t let her have one staffing company — I’d make her have two.”

Dallas said the staffing problems are due to a lack of funding.

The state’s mental and behavioral health care system faced budget cuts in recent years that have severely strained safety net services, officials said at the time. DBHDD Commissioner Kevin Tanner proposed a budget plan this year asking the governor for about $36 million in the next fiscal year, along with a one-time $15 million payment, the AJC previously reported.

Gaps in oversight

The decision to exclude half of the audit’s findings from the corrective action plan leaves employees and public officials left wondering how and when they will be addressed.

“It’s very rich that the department is taking a pass on all of the hard items to say they don’t have oversight. Well, I would like to know who does,” said Erick Allen, a former state lawmaker who also used to work for DBHDD.

State Rep. Mary Frances Williams, who requested the audit, said she felt “incredibly discouraged.”

“Not only did they take allegation by allegation and either say it’s not true or it’s beyond the scope of what DBHDD can handle, they also went on to minimize what I know to be horrific conditions at Mothers Making a Change,” said Williams, who added that blaming workforce challenges in the audit “allowed them to cover up the real problems.”

Dallas wrote in a scathing letter to Tanner that the Cobb CSB was a “tire fire” before the state asked her to step in as CEO in July 2020, and that the state failed to provide proper oversight. She called the audit “highly speculative, laden with unfound assertions and gross miscalculations.”

Tanner declined to comment for this article but issued a statement in support of Highland Rivers (see complete statement below).

“Highland Rivers basically bailed out the Cobb CSB when they needed help the most, especially on the financial side,” said Allen, who chaired the Cobb delegation during the consolidation and monitored the process. “But helping someone clean up their books is completely different than understanding the array of services and service delivery needed in an urban area.”

Staff at Mothers Making a Change honored Loy with flowers and a candle at their recent graduation ceremony.

Credit: Contributed

Credit: Contributed

The year she died, Loy asked her Facebook friends to donate on her birthday to a different rehabilitation program that she had previously attended. She was trying to raise $500 for a program that, she said, saved her life.

“I hope you’ll consider contributing as a way to celebrate with me because if it wasn’t for them I wouldn’t be here today,” Loy wrote. “This is tuition for one month for some lucky woman trying to better her life and overcome this nasty disease of addiction.”

Editor’s Note: This story has been updated to include the complete statement provided to the AJC by DBHDD Commissioner Kevin Tanner.

Complete statement from DBHDD Commissioner Kevin Tanner:

“Highland Rivers and its CEO Melanie Dallas have been major partners in providing safety net behavioral health services and supports for individuals with intellectual and developmental disabilities in Northwest Georgia and metro Atlanta.

“While the audit identified areas that DBHDD will continue to monitor to ensure the quality and integrity of its service array, Highland Rivers’ interventions have no doubt been instrumental in ensuring safety net behavioral health services and disability supports could be maintained in Cobb County since July 2020.

“It’s important to understand the magnitude of the merger between Cobb and Highland Rivers, and that it occurred during one of the most challenging times to provide behavioral health services in history. Community Service Boards across the state are experiencing workforce shortages, which have limited their capacity to increase access to services to meet rising demand.

“Even with these challenges, Highland Rivers has been instrumental in professionalizing the operation at the former Cobb Community Service Board, ensuring the integrity of client’s protected health information, improving relationships with partners in the community and—importantly—increasing access and raising the bar for quality services for the people of Cobb.

“Further, significant strides have been made in managing the fiscal operation, which directly impacts the ability to serve those in need.”

“DBHDD will continue to monitor the performance of Highland Rivers and all entities who are entrusted with public funds to provide critical safety net supports to the people of our state.”

From DBHDD Commissioner Kevin Tanner (through a spokesperson)