[Noozhawk’s note: First in a series on a federal audit of the Santa Barbara County Psychiatric Health Facility.]
A federal and state audit of Santa Barbara County’s Psychiatric Health Facility was published earlier this year, revealing a host of deficiencies in patient care. Since the report was issued, however, officials at the Department of Alcohol, Drug and Mental Health Services, the county division that runs the facility, say the concerns of investigators have been addressed.
The 142-page report was issued in January by the Centers for Medicare & Medicaid Services, the federal oversight body for the organization, and ADMHS officials have since issued a plan of correction. Auditors have signed off on the changes and approved the relicensing process for the 16-bed facility at 315 Camino Del Remedio.
The auditors’ concerns were extensive, and they highlighted everything from how often bed linens were changed to whether the temperature of food being served to patients was safe.
Larger issues also loom, like in the facility’s drug storage room, where staff say controlled substances routinely go missing and records are not kept to document the shortages. The report also said that facility oversight had failed to ensure patients’ rights were protected and that officials had failed to involve patients in their own plans of care.
Based on observations, staff interviews and reviews of administration records, the audit concluded that the hospital “failed to ensure that each patient’s rights were protected and promoted, including participating in the developments of plans of care, development of advance directives, assuring that each patient’s personal belongings and monies were protected.”
The report also says the governing body of the hospital had failed to ensure that restraint and seclusion orders were specific, complete and comprehensive, and said the facility had failed to report the death of a restrained, secluded patient to the Centers for Medicare & Medicaid Services, or CMMS. Alhough the patient’s name was not released in the report, Noozhawk believes the incident refers to Cliff Detty, a 46-year-old Santa Maria man who died April 29, 2010, while in the hospital’s care. The Sheriff’s Department Coroner’s Bureau has ruled the death accidental, but a lawsuit filed by Detty’s father, Rich Detty, is ongoing.
Ten pages of the report were redacted for purposes of patient privacy, according to both the facility’s executive director and medical director. It’s unclear what was included in the missing pages.
The document also says the governing body had failed to ensure that organized nursing service was provided for patients, that adequate nursing staff was on hand to meet the identified needs of patients and that medications were administered as prescribed.
The report also concluded that there was little oversight of contractors. The Community Action Commission, a local nonprofit social services agency, handles the facility’s food contract, and took some particularly hard hits in the audit.
“A tour of the contractor’s kitchen showed an environment that was cluttered and unsanitary,” the report stated. “There was food service that was not maintained in a working condition. Staff practices, including food storage, were not in compliance with good food-safety guidelines.”
The report also mentioned refrigerators that did not have thermometers, and said some temperature logs had not been maintained or checked in three months.
“The hospital served meals at temperatures that were not palatable,” the report stated.
Staff acknowledged that food temperatures were an ongoing problem, and that the hospital doesn’t have anyone to coordinate the activities of the department because of the food production being contracted out.
“The failure of the hospital to have a full-time person responsible for the operation of the dietary services department has resulted in a food service space that is cluttered and unclean, food service equipment that was dirty, and food storage practices that were below community standards and could result in poor food quality and growth of microorganisms,” the report said.
CAC Executive Director Fran Forman talked with Noozhawk about some of the concerns.
“It was a particularly difficult audit,” she said, adding that her organization is used to large amounts of oversight. In addition to the tough audit, Forman said the contract with ADMHS is a tough one that involves a large workload. The company serves food to the facility seven days a week.
Forman said the company is supportive of ADMHS and its mission, and has served the department for more than 10 years without any complaints, but that the audit has drawn scrutiny.
Failure to evaluate the contractor-run pharmacy is also highlighted in the audit. The facility contracts with Pharmerica for those services, and calls for comment to the company were not returned on Wednesday.
According to the report, pharmaceutical services weren’t monitored, accurate accounting records weren’t kept and maintained, and lost or missing medications weren’t investigated.
According to the facility’s documentation, the hospital has no performance improvement activities that track medical errors and adverse patient events, analyze their causes and implement preventative actions. The report mentions a patient death, although the date of the death is redacted, and says there is no documentation that analyzed what happened and recommended how to improve conditions and responses in the future.
The locked unit is a concern mentioned in the report, as well. Camera-equipped observation rooms are used to monitor patients who require use of seclusion and restraint. During a tour in January, regulators found that one of the windows to an observation room had been broken, and was cracked at the top.
“The cumulative effect of these systemic problems resulted in the hospital’s inability to provide safe quality patient care in a safe environment,” the report stated.
Ralph Montano, spokesman for the county Public Health Department, said the facility had issued corrections for each of the deficiencies cited in the audit, and that they had been approved by the Centers for Medicare & Medicaid Services. The facility was required to submit a plan of corrections to address the auditors’ concerns, and afterward, the agency conducts a surprise investigation to see if all of the corrections have been made.
The CMMS approval only came after what amounted to four months of nonstop work by the department, according to Dr. Edwin Feliciano, ADMHS’ medical director.
“We were very successful,” he said, referring to the department’s full compliance. “They were pretty impressed with the amount of work that we had done.”
The facility has never been audited by CMMS before, and Feliciano said he isn’t 100 percent certain why an audit occurred when it did. The guidelines are admittedly stringent, and the psychiatric hospital is held to the same standards as acute general hospitals — like Santa Barbara Cottage Hospital — that have surgical units and other facilities that the PHF doesn’t. That standard requires specific protocols, which could create a burden on smaller facilities. There are more than 200 psychiatric hospitals in California and they’re all held to the same standard.
“It’s definitely additional work,” Feliciano said.
In the past, the department focused its efforts on staying on top of the state Department of Mental Health regulation, which conducts inspections every two years.
“The regulation from CMMS was so out of our view because they never came here,” said Feliciano, who added that the gap between state and federal standards is a big one.
A timely example of that discrepancy occurred when the state Department of Mental Health dropped by for an inspection just two weeks after the Centers for Medicare & Medicaid Services.
“They (the state agency) passed us and said ‘You guys are doing a tremendous job’,” he said.
Another example was the concern that the facility didn’t have an appropriate governing body. ADMHS had committees that examine specific topics, like pharmacy and therapeutics, for the whole system, but not specifically dedicated to the Psychiatric Health Facility.
“That wasn’t sufficient,” Feliciano said. “They wanted to see one specifically dedicated to the PHF.”
As a result, independent committees dedicated specifically to PHF oversight have been established, he said.
Legally, the county Board of Supervisors is the ultimate governing body, but the board has delegated authority to department heads.
“One of the things that (the auditors) said is that there’s no sufficient evidence to say that the Board of Supervisors is the governing body,” he said. “They (the federal agency) couldn’t understand the system.”
Auditors also said that no one leader was specifically overseeing the Psychiatric Health Facility, so ADMHS Director Ann Detrick was named named CEO of the unit.
“Decision-wise, it was the same thing she’s been doing all along,” Feliciano said.
“That actually may have really strong reasoning behind it, because then it doesn’t get lost in the larger scope of data,” he added.
According to Feliciano, one of the things that has improved with the audit is the data tracking and collection. He said tasks like monitoring the pharmacy will be easier now.