On September 22, 2015, two state Nurse-Evaluators from the California Department of Public Health (CDPH) came to Mendocino to conduct a review of Mendocino County Mental Health. On September 28, they issued their “Summary Statement of Deficiencies.” The review was done as part of a “recertification” of Mendo’s de facto Community Mental Health Center. According to the opening lines of the report there were exactly 0 people participating at the time in Mendo’s “Partial Hospitalization Program (PHP),” which they define as “a distinct and organized intensive ambulatory treatment program that offers less than 24-hour daily care other than in an individual's home or in an Inpatient or residential setting,” aka somewhere between hospitalization and simple outpatient care.
PHP is further defined as “time limited, medically supervised programs that offer comprehensive, therapeutically intensive, coordinated, and structured clinical services. Partial hospitalization programs are available at least five days per week but may also offer half-day, weekend, or evening hours. Partial hospitalization programs may be freestanding or part of a broader system but should be identifiable as a distinct and separately organized unit. A partial hospitalization program consists of a series of structured, face-to-face therapeutic sessions organized at various levels of intensity and frequency. Partial hospitalization programs are typically designed for persons who are experiencing increased symptomatology, disturbances in behavior, or other conditions that negatively impact the mental or behavioral health of the person served. The program must be able to address the presenting problems in a setting that is not residential or inpatient. Given this, the persons served in partial hospitalization do not pose an immediate risk to themselves or others. Services are provided for the purpose of diagnostic evaluation; active treatment of a person’s condition; or to prevent relapse, hospitalization, or incarceration. Such a program functions as an alternative to inpatient care, as transitional care following an inpatient stay in lieu of continued hospitalization, as a step-down service, or when the severity of symptoms is such that success in a less acute level of care is tenuous.”
Such intensive outpatient services (which we frankly doubt are being properly provided by Ortner, much less overseen by Mendo’s crack management staff) are reimbursable under Medicare/Medicaid — if they are done under a certified program. For Mendo to remain certified they are theoretically supposed to respond to the deficiencies in the State audit with a “plan of correction” for each deficiency.
The primary deficiency identified by the evaluators was failure to coordinate services between Ortner, various psychiatrists, the drop-in programs, and the drug dispensing organizations. They also found fault with Mendo’s “organization, governance, administration of services, and partial hospitalization services,” Mendo’s “provision of service,” Mendo’s “professional management responsibility,” Mendo’s “environmental conditions,” and Mendo’s “infection control.”
The evaluators picked ten mental health cases at random and found the handling of all of them wanting for various reasons, In one case, “Client 10” which they described in detail, after several months of no follow-up by anyone in the system, the “client” — a Navy vet diagnosed with “schizoaffective disorder” combined with an apparent drinking problem — was found dead in his apartment.
When the evaluators asked why there was no documentation of the vet’s visits (or lack thereof) to the drop-in center, Ortner’s rep replied, “My mistake. I was seeing him briefly discussing follow up when he was seen at the wellness center/drop-in (non-billable services) informally and did not document the visits.”
From the report: “During an interview on 9/24/15, at 1pm, [the Ortner rep] stated that she provided care management, reviewed the plan goals, assisted Client 10 to problem solve, and taught skills according to the treatment plan. [The Ortner rep] stated that she normally called the client one day prior to a scheduled appointment and the day after the appointment if they did not show. When asked why the clinical record did not indicate that for Client 10's 1/13/15 appointment, [the Ortner rep] replied that telephone calls were not billable.”
And, “During a review of the outpatient clinical record for Client 10, the document titled, ‘Progress notes,’ dated 11/19/14, indicated under Intervention: ‘Writer met with client to gather information for clients and updated reassessment following client's recent psychotic episode.’ Under Response: ‘Client reported that his recent episode of not being well was related to having heard news about “the Islamic jihads taking over Iraq and other states,” that triggered bad memories from his time in the Navy’ … Client 10 reported, ‘that he is back on medication (benedryl, lithium, resperidol), but he hasn't been prescribed mellaril, yet. He'd like to take mellaril because it was, ‘good for sleep,’ and reported that he had resumed smoking (“I smoke a lot.”) and drinking occasionally (“I have a beer every once in a while. I don't think there's anything wrong with that.”)’ and stated, ‘I don't mind coming to (named adult contracted service, presumably Ortner’s Access Center) and the [named outpatient medical health provider" (presumably Ortner)… ‘Client agreed to the objectives and signed his updated plan. Client meets criteria for specialty mental health services’.”
“Billability” seems to be important to Ortner and their County counterparts.
The evaluators go on in extensive bureaucratese to imply that Ortner’s failure to follow up on the vet’s case may have lead to his death. Although they do not identify the cause of death, we can probably assume it was suicide.
At this point, the report coldly notes, the Ortner case manager “closed the client’s file and gave it to the executive director to lock up.” (That task, we assume, was billable.)
The rest of the report is either a summary of various documentation gaps which lead them to conclude that Mendo and Ortner’s organization, management and administration were deficient or that conditions in Ortner’s facility were lax — improper storage of needles and urine testing kits, etc.
(Aside — Years ago I conducted an audit of McDonnell-Douglas’s contract logistics services while working in the St. Louis Air Force Plant Rep Office (AFPRO). My audit partner and I ran down a list of several dozen deficiencies with the contractor’s cost and schedule performance in front of McDonnell-Douglas’s grumpy, irritable Senior VP of Operations Joe Boyd, and McDonnell-Douglas’s Program Manager Arlen Dombrick. Boyd had very little respect for the opinions of the AFPRO because we were generally nothing more than a bunch of bean counters and quality control checkers who nitpicked his operations for minor problems which shouldn’t even have occurred, much less been noticed. Yet here we were listing a series of both major and minor problems which Boyd was increasingly unhappy about. Boyd turned to Mr. Dombrick and loudly grumbled, “You mean, you can’t even convince the AFPRO you’re doing a good job?”)
This report by the Department of Public Health falls into a similar category. If a supposedly professional organization like Ortner can’t even convince the casual nurse inspectors from Public Health that they’re doing their job — and in fact don’t even document client visits, coordinate their services, and don’t follow up with phone calls because it’s “not billable” (!) — you have a serious problem on your hands.
We have a call in to the CDPH District Office in Santa Rosa to see how these deficiencies are supposed to be addressed. (Theoretically, Mendo could be decertified from PHP billing and/or their Mental Health service bills could be denied.)
But don’t be surprised if this latest critical report of Ortner and Mendo Mental Health gets papered over or ignored like the rest of them.
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One of the main the reasons that nothing much improves in the Health and Human Services Department is the simple fact that you can’t get a straight answer out of them about anything. When the Ukiah Daily Journal asked HHSA boss Stacey Cryer about the recent audit of mental health by the two nurse-evaluators from the State’s Department of Public Health, Ms. Cryer “disputed the survey finding Tuesday, saying county mental health hasn’t had a PHP, nor has it billed for Medicare services, in at least a decade.”
What does that mean?
A PHP is a “partial hospitalization program” or basically an intensive supervised outpatient program which obviously some mental patients need or it wouldn’t be in the range of services that should be offered. The context in which it was first raised in the audit was: “A Community Mental Health Center must provide day treatment or other partial hospitalization program services, or psychosocial rehabilitation services.”
So obviously, the evaluators were referring to a type of service that County mental health departments are required to provide, not some narrowly construed program or billing process which Ms. Cryer may personally think they’re referring to. On top of that, why doesn’t the County have a PHP? Surely there are Mendo people who need supervised outpatient services.
Here we have a professionally conducted state audit alleging that an inexcusable lack of coordination of services and lack of follow up probably lead to the death of a mental health client with a County management staffer quoted in the report as having admitted that “it appears as though this client’s care has fallen off a cliff…”
And all we get in response from the person in charge is a non-sequitur? Not even an “I’m sorry,” or a “We’re looking into it,” or “That information is confidential” or, “all of that will be addressed in the upcoming Kemper Mental Health audit”?
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