AUGUSTA — A recent scathing report by federal regulators criticizes Riverview Psychiatric Center for a slew of missteps, including unreported medication errors and record-keeping failures, suggesting even deeper problems than previously revealed at the state mental hospital.
The federal report, filed June 27 with the Department of Health and Human Services, comes as the hospital is trying to regain certification after losing about $20 million a year in federal reimbursement money last September.
The federal government revoked Riverview’s certification last year based on inspections, including the disclosure that Kennebec County sheriff’s deputies had used stun guns and handcuffs to control unruly patients at the hospital.
Riverview had recently asked to be certified as a 72-bed psychiatric hospital – 20 fewer beds than the hospital has available – a request that prompted the new federal inspection and report.
The federal Centers for Medicare & Medicaid Services rejected the certification request and found numerous deficiencies with regard to tracking patient treatment: failures to document assessments, undocumented treatments, too few pharmacy workers, and no time allotted for mental health workers to work one on one with patients.
Riverview Superintendent Jay Harper said the report’s criticism is legitimate, but that the top problem is the hospital’s failure to document when a patient is receiving the treatment called for under an individual patient plan.
“I think it’s the words that they have to use,” Harper said of the new report. “It doesn’t sound good at all. We never denied that was definitely our weak place going in. We thought we were close and they showed us we weren’t, so we went back to the drawing board.” He said he intends to request a new evaluation.
LITANY OF DEFICIENCIES
Federal regulators who inspected Riverview in May said the hospital failed to note the progress or lack of progress in treatment for eight different patients among a sampling of about 30 patients.
In one case, a patient was being treated for pedophilia by attending “weekly psychotherapy with an outside contracted sex offenders treatment specialist consultant ‘for months,'” according to a nurse. Yet the patient’s treatment plan lacked any mention of those visits.
The federal regulators’ report says Riverview “is not in substantial compliance with the Medicare conditions of participation for psychiatric hospitals” following a May 15 health and safety code survey by state and contracted psychiatric hospital surveyors.
The litany of deficiencies starts at the top, saying the superintendent – Harper, who was appointed in March – “failed to ensure that the hospital was managed in accordance with the hospital policies regarding the medical necessity for admission and policies and procedures regarding adverse events and medication errors.”
Harper took over at the hospital after Mary Louise McEwen, Riverview’s superintendent for nearly five years, was ousted in a DHHS-directed leadership change.
Riverview’s medical and clinical and social services directors also were faulted in the report, saying they failed to monitor and evaluate the quality of the care provided there.
“Our treatment plans are just horrible,” the nursing director is quoted as saying.
The regulators’ report says 13 of 32 admission records reviewed failed to document that the patient met required admission criteria.
“All 13 records contained documentation indicating that the patient did not meet medical necessity criteria for inpatient hospitalization at time of admission,” yet all were admitted to Riverview, it says.
It also reports that seven of those patients remained there despite a “determination that continued stay criteria was not met.”
‘WE DON’T HAVE TIME FOR THAT’
The report says the hospital failed to notify a physician of medication errors that occurred in four of five patient records reviewed and “failed to assure physicians’ orders were signed for three of 31 patients,” and didn’t mark allergies on a medical staff order sheet for one patient.
The hospital was faulted for failing to get informed consent before treatment of at least one patient and for failing to document continuous one-on-one monitoring of two patients after a physician ordered it for patient safety.
Harper said the hospital has instituted a daily debriefing to follow up on every instance of involuntary medication in a psychological emergency.
Regulators said treatment plans lacked alternatives for when patients refuse to attend regular group sessions.
One patient was expected to attend “open rec, social groups, fitness current events, social skills, community meetings, bending therapy, education film and creative expressions,” all on April 16, but refused to do so and lay in bed all day, according to a nurse.
A mental health worker told regulators the patient was encouraged to go, but that no one-to-one interaction was done.
“No, we don’t have time for that,” the worker told the federal reviewer.
To resolve the pharmacy staffing problem, Harper said a third pharmacist was added this year and the pharmacy tech status will be reviewed to see whether additional changes are needed. The hospital contracts with an outside provider for pharmacy services.
Harper said he planned to send a new request to the federal government to ask for another hospital evaluation. He acknowledged that when the inspection was conducted in May, the hospital wasn’t keeping good records.
“The treatment plan is a contract between us and federal government that we’re going to deliver X-Y-Z to patient 42,” he said.
“How do you demonstrate that you did X-Y-Z to patient 42? Their objection was reasonable. Basically, we didn’t do a good job of that.”
He said sometimes Riverview patients are moving toward recovery “but because the documentation is so bad, we don’t know what our successes were.”
He said that the treatment plans are being revamped now, and he expects the hospital to receive good marks in the next inspection.
“They’re really looking for systemic change,” Harper said of federal regulators.
“They don’t want you to go case by case and problem by problem.”
Harper said the hospital has concentrated first on safety and patient rights. Federal regulators arrived unannounced in 2013 following the reports about corrections officers using stun guns to subdue aggressive patients in the forensic unit of the hospital. Forensic patients are those who have committed serious crimes.
The guards were brought in after Mark Murphy attacked a pregnant mental health worker, beating her and stabbing her in the hand with a pen. Murphy was found guilty of aggravated assault in that attack and was sentenced to the Maine State Prison.
“If you don’t make the place safe for patients and staff, there can be no treatment,” Harper said.
He said the final element is the treatment plan and recording whether the treatment is taking place, and if not, what needs to be changed. Harper said the format for indicating patients met hospital admission criteria was changed to reflect that forensic patients were sent there as a result of a judge’s order.
Civil patients are admitted only after going through a psychiatric assessment at another hospital. There are no direct civil admissions to Riverview, Harper said.
As well as seeking certification as a 72-bed psychiatric hospital, Riverview has appealed a federal decertification over 20 beds in the Lower Saco unit, where the most aggressive forensic patients are placed and watched by “acuity specialists,” who are mostly former corrections officers.
If the hospital can obtain certification from the Centers for Medicare & Medicaid Services as a 72-bed psychiatric hospital, the plan is to then work on getting the other 20-bed unit recertified as well, Harper said.
In the meantime, the hospital is losing about $20 million a year in federal reimbursement funds and being supported entirely by the state.
The hospital was built in 2004 and designed to be “a center for best practice, treatment, education and research, for individuals with serious, persistent mental illness, and co-occurring substance use disorders,” according to the state website.
The hospital has 92 beds divided almost evenly between forensic patients and civil patients. On Thursday, 76 beds were occupied, according to Harper.
“The appeal process is out of (the DHHS) commissioner’s office,” Harper said.
“My understanding is that they are waiting for the feds to respond.”