Pattern of ‘life-threatening’ prescribing errors at Mind Springs Health, survey finds

A pattern of ‘serious and life-threatening’ prescribing errors by the struggling mental health center responsible for treating 10 West Rim counties is putting patients at risk, according to investigation findings that state agencies have been hiding to the public for more than nine months.

State officials have not released the June 2021 findings despite growing public concerns about Grand Junction-based Mind Springs Health and its psychiatric hospital, West Springs. The problems were so acute that the state’s Medicaid contractor would not authorize payment for newly admitted inpatients for three months until Mind Springs agreed to make far-reaching changes.

The survey found that out of a sample of 58 Mind Springs outpatients, almost half received care classified as having potentially “serious and life-threatening impact”. Two people included in the review have died, although public records do not directly attribute their deaths – one from respiratory failure and the other from a prescription drug overdose – to the quality of their care .

“If there are things that are being investigated there and issues that are uncovered, the public has a right to know,” said Wendy Wolfe, a Summit County resident whose son has been treated by Mind Springs for over seven years. “Without public disclosure, how else do we know it’s safe to send our families, our community there?”

State regulators declined to say why they did not alert the public to prescription errors. Mind Springs executives did not recall the results of the survey, launched last spring by Rocky Mountain Health Plans.

RMHP is Colorado’s privately held Department of Health Care Policy and Funding Contracts to administer and pay Medicaid benefits on the West Slope. Under the contract, the company is one of those investigating complaints about Mind Springs and two other community mental health centers in Western Slope.

The RMHP detailed its concerns in a June letter to the Chief Medical Officer of Mind Springs. They included:

  • In the sample of 58 outpatients who were prescribed high doses of a tranquilizer benzodiazepine between February 2020 and February 2021, the quality of care provided to 52 of them was of concern. .” Mind Springs medical staff had prescribed many of these patients high doses of stimulants in addition to their benzodiazepine, which puts a patient at risk of overdose. Benzodiazepine use is also particularly risky for people with substance use disorders.
  • Nearly half of a sample of 54 people receiving hospital care in West Springs had received deficient care. These patients were readmitted to the psychiatric hospital from February 2020 to February 2021 within 30 to 60 days of discharge.
  • Concerns about prescriptions that included prescribing controlled substances with a 30-day supply for high-risk patients and refills given to patients with opioids or other addictions without a visit.
  • Failure to document “specific rationale for prescribing controlled substances” for clients receiving hospital care.

Mind Springs cut outpatient services after opening a $34 million mental hospital in December 2018 that doubled its inpatient beds from 32 to 64. It spends nearly three times as much on hospitalizations as other mental health centers community and its patients are readmitted at four times the rate, payment data shows.

“If you look at the data, look at the readmission rates and the follow-up after the patient is discharged…Mind Springs Health continues to be, at the hospital, off the charts compared to other psychiatric hospitals,” David Mok-Lamme, a Rocky Mountain Health plans executive said at a recent town hall meeting in Mesa County. “We’re talking about multiple readmission rates and a fraction of the follow-up rate.”

Rocky Mountain Health Plans conducted its investigation last spring after a Mind Springs doctor contacted the company about concerns about Medicaid management, prescribing practices, lack of peer review and other treatment issues that the whistleblower said were harming patients at Mind Springs facilities.

The Department of Health Care Policy and Funding released the letter detailing the Rocky Mountain Health Plans findings only after its executive director, Kim Bimestefer, learned that reporters from the Colorado News Collaborative and the Colorado Springs Gazette l were getting another way.

Last spring’s survey determined that of the sample of 52 outpatients whose treatment was of concern, a physician was involved in the care of 18, or 35%, of those clients.

Records show that a psychiatrist, Dr Thomas Newton, resigned from Mind Springs in May after being placed on administrative leave due to “aberrant prescribing” practices revealed during the investigation. Newton remains licensed to practice medicine in Colorado, and physician licensing regulators at the Colorado Department of Regulatory Agencies have not released details of the controversy over his care in Mind Springs on its online licensing search tool. . Newton did not return phone calls, text messages and emails seeking comment.

An elderly Mind Springs patient, who later died, was discharged from West Springs Hospital with prescriptions for high doses of benzodiazepine and other drugs which, when used together, can cause breathing problems, according to investigation. The man’s death was due to respiratory failure, although the inquest could not definitively link him to improper care. Another patient who received no follow-up care after being discharged from West Springs died from an overdose of painkillers.

The whistleblower doctor’s allegations were so serious that in April, Rocky Mountain Health Plans denied Mind Springs payment for new hospital admissions. The stoppage of payments was lifted after Mind Springs agreed to a corrective action plan in June.

Records show that for much of the past year, Mind Springs has remained under this corrective action plan, which requires its facilities to make 17 protocol improvements to prevent similar life-threatening errors. Although many of these changes have already been made, Mind Springs is still finalizing some of the new protocol requirements.

Other problems have emerged since the conclusion of the outlier prescribing survey.

In December, Rocky Mountain Health Plans informed state health officials that from July 1, 2018 through December 15, 2021, it had reviewed 472 quality of care issues involving Mind Springs and West Springs. Of these, 251 – almost 60% – had some validity, with 68 of them – or 16% – having posed serious and life-threatening risks to patients. Some of these cases occurred after Mind Springs agreed to corrective action last spring.

Reporting by the Colorado News Collaborative in December prompted the three state agencies overseeing community mental health centers to launch an audit in January to determine whether Mind Springs is not serving the public.

The health department found “zero deficiency,” according to its records.

The Department of Social Services found only administrative problems. These range from Mind Springs’ inability to report 40% of critical incidents such as prescription errors or injuries to the state within the required 24 hours, to its tendency to release patients from its hospital without proper documentation. appropriate for further treatment.

Mind Springs CEO Sharon Raggio and two of her other top executives have resigned since December, when the Colorado News Collaborative revealed the organization’s long history of not providing security care for which it is paid dozens. millions in the state and federal government. taxpayers’ money every year.

This story was reported as part of the Colorado News Collaborative, a coalition of more than 160 news organizations across the state.

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