Review of
UHS HARTGROVE HOSPITAL

Prepared for the
Illinois Department of Children and Family Services

Mental Health Policy Program
Department of Psychiatry
University of Illinois at Chicago

 Table of Contents

Executive Summary
I.

Scope & Methodology of the UIC Review

II. Summary of Preliminary Findings
•

June 16 & June 27 Memos

III. Summary of General Findings
•
•
•
•
•
•
•
•

Hospital-related findings
Sleeping patients on cots in hallways
Inadequate staffing levels and staff supervision
Inadequate staff training and hospital oversight
Treatment planning and clinical issues
Selected Case Reviews of DCFS Wards
UHS Hartgrove Staff: In Their Own Words
Corporate-level Accountability Issues

Conclusions & Recommendations

List of Attachments
•
•
•
•

Centers for Medicare & Medicaid Services:
Report of 2011 Survey at UHS Hartgrove Hospital
Department of Justice press release and complaint
IDPH 2009 survey report on UHS Hartgrove Hospital
News media reports on UHS facilities in other states

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I. Scope and Methodology of the UIC Review.

Executive Summary

The UIC Mental Health Policy Program was asked to conduct
a quality of care review of UHS Hartgrove Hospital on behalf of
the Illinois Department of Children and Family Services.1 2
•

The UIC team initiated its review process in November 2010
by observing staff-patient interactions on all hospital units
serving DCFS wards; these observational visits were random
and unannounced, occurring on all shifts over an extended
period through June 2011.

•

Interviews were conducted with hospital administrators at
various levels, including the CEO, medical director and other
senior managers at the facility. UIC reviewers also spoke with
current and former UHS Hartgrove direct-care staff, therapists
and other mental health professionals who were familiar with
the clinical operations of the hospital; further, each of these
individuals examined the data presented below in Table 1 and
affirmed that it accurately reflected the level of chaotic and
often aggressive outburst on the hospital’s units.

•

A database list of all admissions of DCFS wards from January
2008 through December 2010 was generated, from which a
sample of DCFS wards – all of whom had multiple inpatient
admissions to UHS Hartgrove or other psychiatric hospitals –
was then selected for closer evaluation.

UHS Hartgrove Hospital

Additionally, individual case reviews and interviews were
conducted with DCFS wards not in the original sample who
were hospitalized during the timeframe of the on-site review.
UIC reviewers also observed treatment team review meetings
for a number of these currently hospitalized wards.
•

Approximately 12,000 pages of documents were reviewed,
including: medical/psychiatric histories of wards; treatment
and discharge plans; minutes of the medical executive staff
committee and risk management committee meetings; policy
and procedure guidelines; and unusual incident reports.

1

The review team was headed by Dr. Ronald Davidson, director of the UIC
Mental Health Policy Program, and included: Cynthia Petty, APRN; Forrest
Brown, RN; Dr. Barbara Fish; and Christina Kraemer, LCSW. Dr. Michael
Naylor provided consultation and clinical data reviews regarding certain
medical and psychopharmacological issues, and Dr. Christine Davidson
provided database analysis on hospitalization records of DCFS wards.
2

UIC team members appreciated the cooperation of UHS Hartgrove officials
and staff members during the review process. Dr. Davidson and Dr. Naylor
discussed certain critical findings of the UIC report with the CEO, medical
director and director of nursing of Hartgrove at a meeting on August 25.

 
  

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•

Included in the documents reviewed by the UIC team were
reports of surveys conducted by the Illinois Department of
Public Health on behalf of the federal Centers for Medicare
and Medicaid Services. CMS Region 5 officials in Chicago
also provided a 2011 report on UHS Hartgrove, pursuant to
a Freedom of Information Act request submitted by the UIC
team, which will be discussed at length below.

•

During the course of the review, the UIC team learned about
troubling reports suggesting a pattern of quality of care issues,
harm to patients or major healthcare fraud charges involving
UHS-operated facilities in a dozen other states beyond Illinois:
Virginia, Tennessee, Pennsylvania, North Carolina, California,
South Carolina, Massachusetts, Connecticut, Texas, Nevada,
Arkansas and Missouri.
Accordingly, the UIC team submitted Freedom of Information
Act requests for survey reports by state and federal agencies
and examined news media reports, federal court documents
and other data indicative of ongoing quality of care problems
within certain facilities operated by the UHS corporation.
Telephone interviews were also conducted with federal and
state agency officials in Illinois, North Carolina, Pennsylvania,
Missouri, Virginia, Nevada, California and Washington DC
to verify the findings and subsequent actions arising from
surveys of certain UHS facilities. UIC reviewers also spoke
with patients, family members, news media reporters and
other persons familiar with the findings of the federal and
state surveys of UHS facilities in other parts of the U.S.

•

UIC reviewers learned that the U.S. Department of Justice
filed a complaint in federal district court in Virginia in 2010,
charging Universal Health Services and one of its facilities
with violating the federal False Claims Act [see attachments].3
Since the DOJ allegations of fraud in this matter specifically
identified substandard quality of care– including inadequate
treatment planning, poor clinical care and lack of supervision
of staff – as the basis for the government’s complaint against
the UHS corporation, the current UIC report will examine this
and other relevant cases below.4

3

United States of America v. Universal Health Services; filed 08/06/10 in
U.S. District Court for the Western District of Virginia.
4

See also: Department of Justice press release – “U.S. Files Complaint
Against Virginia Medicaid Providers,” indicating that: “the defendants billed
Medicaid for inpatient psychiatric care that was not provided, in violation of
federal and state Medicaid requirements, and falsified records to cover up
their serious violations.”

2

 Xxxxxxx

Report of Preliminary
Findings to DCFS on
June 16 & 27, 2011.

II. Summary of June 16 preliminary findings.
The UIC review team provided a brief summary memo about
certain preliminary findings at UHS Hartgrove Hospital to the
director of DCFS on June 16; the memo was occasioned by a
discussion with the director and the DCFS chief legal counsel
regarding an apparent increase in violent incidents at the facility;
the memo included a list of 50 incidents that occurred between
December 2010 and mid-June 2011; an updated list detailing
100 incidents was sent to DCFS on June 27 [see attachments].
On the basis of the June 16 memo, the director immediately
ordered an intake hold with regard to new admissions of DCFS
wards to the hospital. UHS Hartgrove officials were sent a copy
of the June 16 memo by the DCFS chief counsel.
The June 16 memo to the director noted, in part:
•

“The UIC team was especially struck by the warning sounded
by a confidential staff source very early in the review process:
that “’violence is an everyday occurrence at this hospital.”
“Observations at UHS Hartgrove by the UIC reviewers over
the following six months found evidence of a consistent pattern
of violent, aggressive and chaotic incidents in the facility (with
patients attacking other patients as well as unit staff) and other
troubling behaviors (including sexual acting-out), all of which
will be detailed at length in the final UIC report.’”
“Recent interviews with patients and staff sources suggested
that such high-risk incidents appear to have increased within the
past few months, and a brief examination of incident reports for
May-June 2011, conducted yesterday at the hospital, tended to
support this finding.”
“The UIC review team examined a selected sample of 50
unusual incident reports, primarily involving overt acts of patient
aggression toward others (running from December 2010 through
June 15, 2011): the last 30 UIRs occurred during the six-week
period of May 1 through June 15.”

Of immediate concern, the memo noted, when two members
of the UIC team arrived at Hartgrove at noon on June 13 they
observed the aftermath of a particularly disruptive morning:
•

At least three fights had already occurred on the adolescent
boys unit before the UIC reviewers arrived, all involving youths
who were non-wards.
A DCFS ward told UIC reviewers about witnessing one of the
fights, saying that a new patient came into a group in the unit
dayroom and suddenly started punching another patient “for no
reason,” adding that “he didn’t even know the kid, just punched
the kid sitting there.”

3

 •

These fights were followed by an aggressive episode in which
another non-ward reportedly struggled with staff as he attempted
to jump the counter to get into the central nursing station (similar
occurrences involving the unit nursing stations are detailed in
[the attached table] below [and in other attachments]).

•

Another ward tearfully described the morning’s events to the
UIC reviewers, and he appeared frightened by these sudden
chaotic outbursts on the unit; it was apparent that he was quite
anxious about whether he could feel safe in the unit milieu.

•

The UIC reviewers later observed a staff member alone with
22 patients in the dayroom, apparently waiting for lunch to
arrive. The staff member told the group that because they
wanted to act up and fight earlier in the morning, staff had to
shut down the unit and impose order.
He said he understood that it can get frustrating because…
it is hard to walk away and find staff to talk to because they are
so busy. He told this group of patients that the hospital pays him
to keep kids safe, and that is his priority. “People can get hurt,”
he said, “and not just hurt, destroyed.” This staff member later
said to one of the UIC reviewers, “There are just too many
people up in here.”

•

UIC reviewers also learned of another incident that occurred
a few days earlier, June 9, in which three boys had been left
unmonitored by staff in the unit dayroom that evening for as long
as 10-15 minutes, during which time they reportedly engaged in
sexual acting-out behaviors.

Among the list of 50 incidents – later updated to 100 incidents
– attached to the June 16 memo, the five case examples below
offer a representative sample underscoring the UIC findings:
•

01.22.11 Observation notes by UIC reviewer on girls unit.
For most of the afternoon shift a severely mentally ill female
adolescent repeatedly announced that she was going to hit
someone as she roamed the hallway without staff supervision.
The dayroom was locked in order to “keep someone from
coming in.”
In the dayroom, one girl attacked another, tearing out her hair
and punching her in the face.; victim sustained a swollen eye

•

03.08.11 – LJ Interview with UIC reviewers.
Pt stated: “I don’t like it here; the girls get violent. I’ve never
been in a fight. I feel panicky if the dayroom gets loud, but
sometimes staff don’t let me leave.” When asked if she felt
safe at Hartgrove she started to shake.

•

03.22.11 – GN Interview with UIC reviewers.
Pt reports that he “doesn’t feel safe,” saying “kids try to
fight me all the time.” Admits to problems managing his
own temper.

4

 •

06.14.11 – RK Interview with UIC reviewers.
Pt stated: “Kids here act up every day. There was a fight at
the end of the hall; one kid walked up behind another kid
and just started punching him in the dayroom, and then
they were fighting in the hall.”

•

5.20.11 – DG interview with UIC reviewers.
During an interview in dayroom with (DG), two non-wards
seated nearby told the UIC reviewer about their concerns
for DG’s safety at Hartgrove, and they urged that DG be
sent “someplace safer.”
Both youths, who were bigger adolescents, explained to
the UIC reviewer that they had been “looking out” for DG
(who is small in stature) because he often “annoys and
provokes people,” which they said made him a target for
attack [by other youths].
Since both of these boys were going to be discharged
from the hospital within the next two days, they said,
“there won’t be anyone here to look out for him after
we’re gone; you need to get him out of here..”

When the UIC reviewer again examined DG’s chart the next day,
a special note was discovered:
“Pt denies ever feeling intimidated by peers
or ever having feelings of being unsafe. He
denies ever verbalizing those kinds of feelings
to staff or peers.”
This curious note was entered following a meeting between
the UHS Hartgrove CEO and three UIC reviewers on 5/21/11
– including Dr. Davidson and the UIC team member who had
spoken with DG and the two non-wards a day earlier; part of that
meeting focused on the DG interview and the safety concerns
raised by the two non-wards).
It would appear from the chronology of events, therefore, that
UHS Hartgrove officials thought it appropriate to ask a mentally
ill and cognitively impaired child to essentially “vouch” for his own
personal safety in the hospital. Despite this highly questionable
endorsement by this DCFS ward, it should be reiterated that it
was the two non-wards – not DG himself –who feared for his
safety and consequently took if upon themselves to protect him.
The UIC team discovered very early in the review process that
it could not rely on UHS officials to be entirely forthcoming
about problems at the hospital, the June 16 memo concluded,
despite repeated assurances of transparency:
•

Confidential sources said that Hartgrove officials indicated they
would add extra staff to the hospital units during the course of
the UIC review, thereby giving a misleading impression that
staffing levels were higher than the normal pattern.

5

 •

UHS administrators were assigned to closely track the UIC team
members during each visit to the facility, taking notes whenever
the reviewers spoke with either patients or staff; several DCFS
wards indicated they were later questioned about what they had
said to the reviewers, and it was clear they were made to feel
anxious about meeting with the UIC team.

•

Perhaps most disturbing, Hartgrove staff were reportedly told by
UHS officials that anyone suspected of providing information to
the UIC reviewers would be fired.

Further, while most of the incidents detailed in the June 16 and
June 27 memos involved DCFS wards – either as victims or
perpetrators of violent acts – the observations and data analysis
by the UIC reviewers found it was just as likely that non-wards
were involved in such incidents; indeed, hospital records show
numerous incidents of aggression that involved only non-wards
(or non-wards attacking DCFS wards).5 6 7
In sum, while the June memos were limited to the single issue
of whether such violent episodes posed immediate risks to the
health and safety of DCFS wards at UHS Hartgrove, the general
scope of the UIC review examined a broader array of concerns
about this facility, as will be discussed below.

5

The UIC reviewers were informed that UHS Hartgrove administrators
have repeatedly asserted – to DCFS officials, hospital staff and others –
that DCFS wards are the primary cause of the violent or sexual incidents
at the facility; in fact, this is simply untrue.
Further, UIC sources at the hospital indicated that UHS Hartgrove officials
have admitted significant numbers of youths from the Cook County Juvenile
Detention Center and the Illinois Department of Corrections; since many of
these youths arrive at the hospital with well-established histories of violence
in the community, any efforts by UHS administrators to cast blame on DCFS
wards for the epidemic of aggressive behaviors at Hartgrove ought to be
seen as disingenuous.
6

Of interest, UIC’s sources at the hospital indicated that Hartgrove officials
significantly increased staffing levels shortly after the intake hold was issued
by the director of DCFS. One positive effect of this sudden staffing increase,
according to the UIC informants, is that the level of aggressive behaviors by
patients dropped significantly; one UIC source at Hartgrove sent a brief text
message saying: “no fights on unit last 3 days – amazing!”
7

Table 1, beginning on the following page, is the updated and corrected list
of 100 incidents attached to the June 27 memo to the director of DCFS.

6

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Table 1.

November 2010 through mid-June 2011

Sample of Hartgrove incidents
involving physical assaults,
sexual assaults/behaviors,
or uncontrolled conduct that
threatens safety of the milieu.

The following 100 incident reports and other documents written by the
UHS Hartgrove Hospital staff illustrate concerns regarding immediate
safety risks – involving physical assaults, sexual assaults or sexualized
behaviors, and related problems of uncontrolled aggressive/threatening
conduct or high-risk behaviors – that undermine the quality of care and
8
treatment provided to DCFS wards in this facility.
1. 11.06.10 – AD
Pt attacked by four girls on the unit; she attacked staff when
being escorted to the quiet room.

 
  

2. 11.11.10 – MB
Staff discovered MB on bathroom floor in his room, bleeding
from a self-inflicted wound; he reportedly lost 150-200 cc of
blood after cutting himself with a plastic knife he had hidden
for several days. Pressure dressing applied; pt sent to ER.

 
  
 
   
   
   
   
   
  

 
  

Violence has become
an everyday occurrence
at this hospital… and it’s
very frightening for the
kids and staff alike.

3. 11.17.10 – AG
Pt assaulted peer in dayroom; FLR, IM.
4. 11.26.10 – JA, TT & AJ
Three separate aggressive incidents involving attacks on
patients (JA & TT) as well as staff (AJ); in the latter instance,
staff were attacked while handling another aggressive patient.

 
  
 
  

5. 12.02.10 – SS
Staff discovered female pt performing oral sex on (DCFS
ward) in her bedroom. Ward, SS, was noted to be “defiant,
aggressive…, explosive.” Code called, pt escorted to QR.

 
  

Comments by a UHS Hartgrove Hospital
staff member in a December 2010 meeting
with the UIC review team.

 
  

Of interest, on 12.01.10, the day before this sexual incident,
SS was observed “stalking females” on the unit. Even after
he was placed on 1:1, a note (12.08.10) showed that SS was
observed continuing to stand by the female patient’s room.

 
  

 
  

DCFS hotline was apparently not notified about this sexual incident
since both patients were 18.
6. 12.05.10 – TJ
Pt called other peers a “bitch.” Peer attempted to choke pt
and threw punch at TJ’s face.
7. 12.09.10 – SD
Pt unpredictable…, attacks other peers at will.
8. 01.10.11 – MC
Multiple altercations with peers; pt moved to another wing.

8

Note: several items are derived from interview notes by the UIC reviewers.
Certain items were edited by the UIC reviewers for grammar/syntax for the
purpose of clarity or readability; emphasis was also added (boldface and/or
italics) to highlight relevant sections.

7

 Xxxxxxx
9. 01.18.11 – LB
Pt attacked a peer in the unit dayroom; victim sustained
a nosebleed.
10. 01.22.11 Observation notes by UIC reviewer on girls unit:
For most of the afternoon shift a severely mentally ill female
adolescent repeatedly announced that she was going to hit
someone as she roamed the hallway without staff supervision.
The door to dayroom was locked in order to “keep someone
from coming in.”
In the dayroom, one girl attacked another, tearing out her hair
and punching her in the face.; victim sustained a swollen eye.
The UIC reviewer was left alone with the other patients for several
minutes as staff attempted to manage this episode.
11. 01.27.11 Observations by UIC reviewers on boys unit:
Two fight on day shift; in one case, two boys punched each
other, with one sustaining a bruise and scratch on his eye.
At 3:15 PM one boy punched another in the face. Per staff,
this patient instigated several fights during prior 24 hours
– “but somehow [the patient] got back into the dayroom.”
At 3:40 PM five boys were moved to the other side of unit.
Multiple staff struggled to stop a fight that broke out, while
five boys from the other side of the unit looked on through
the window; they were not under any staff supervision.
During this violent episode there did not seem to be anyone
taking authoritative charge of the unit, resulting in confusion
and a lack of staff supervision for about 20 minutes.
12. 02.22.11 – DW
Pt observed running after peer in hall, hitting peer on the head
with hand. Pt T/O in room, went to QR.
13. 02.23.11 – DW
Pt in middle of hall calling peers out to fight. Pt was observed
kicking at peers and trying to punch them in face.
14. 02.27.11 – SP
Pt had physical altercation with peer. Peer struck him with fist
in right eye. Pt defended self, no harm inflicted on peer. Right
eye was reddened with minor swelling.
03.04.11 UIC interview with SP:
“Pt came up from behind and started hitting me last week
at breakfast. I got hit on the back of the head and left ear.”
“Third fight here at Hartgrove” (pt identified two other boys
he’s fought with who are still in the hospital).”
“First fight: “some dude ran into my room the first or second
week that I was here; staff grabbed him and me.”

8

 15. 02.27.11 – SP
Pt isolated and withdrawn until battered by peer; pt fought
and was then restrained by staff members.
16. 02.28.11 – TD
Pt removed from groups as he got violent and aggressive
toward peer. Escorted to QR.
17. 03.01.11 – TD
Pt redirected multiple times to stop jumping on nursing station.
18. 03.02.11 – TD
Pt hit peers and threatened to punch staff on several occasions.
Continued aggressive behaviors for one hour.
19. 03.02.11 – AB
Pt was crying, then started screaming and throwing the chart,
unable to control self, climbed over nursing station; grabbed
[magnetic key card] from staff and started toward exit door.
20. 03.03.11 – DH Treatment Plan Review:
Pt was involved in multiple physical altercations with peers
in which he was punching, kicking, running in peers’ rooms.
21. 03.04.11 – TG Interview with UIC reviewers:
Pt reported “a fight daily for the past two weeks; there was
a fight this morning between two boys after breakfast.
“We have to go to our rooms; during fights all the kids have to
stay in their room; then we get to talking across the hall, and
if we don’t stop we stay in our rooms. If there’s a fight, all kids
get punished with no cafeteria.”
22. 03.04.11 – WS Interview with UIC reviewers:
Pt reports he’s “seen a lot of fights on the unit. Code is called
for a fight, staff come from another unit. They shut unit down,
no free time rest of night after fight happens. Happens about
twice week, could happen at dinner time.”
23. 03.08.11 – LJ Interview with UIC reviewers:
When questioned about her experience at Hartgrove, pt replied:
“I don’t like it here; girls get violent, I’ve never been in a fight.
I feel panicky if the dayroom gets loud. but sometimes staff
don’t let me leave.”
When asked if she felt safe at Hartgrove she started to shake,
adding: “Bedtime is about 9 PM, so it depends if the other girls
scream, yell, get dragged from their rooms.”
24. 03.08.11 – TT
On evening shift, pt hit male charge nurse in the forehead
with her hand. Zyprexa 10 mg. IM for agitation.
25. 03.17.11 – AC
Pt reported altercation with peer earlier in AM over nothing…
and slapping the peer.

9

 26. 3.21.11 – DW
Pt in fitness group when he got into fistfight with roommate.
27. 03.21.11 – CS
Peer started to walk into CS’s room. CS struck her in forehead
with fist. Two hours later CS tried to go into same peer’s room
to attack again.
28. 03.22.11 – JD Interview with UIC reviewers:
“Me and another guy fought each other. I got cut right wrist;
back was sore” [attributed sore back to floor restraint by staff].
29. 03.22.11 – ED Interview with UIC reviewers:
Pt stated: “Things are going OK, but the program is chaotic.
Lots of gang stuff, talk about weed and glorifying violence. Staff
try their best to handle it appropriately.”
“Lots of fighting, people peeking in rooms, lots of bullying,
talk about people’s sexuality, how people look. Fights happen
on weekends and on evenings. At night there’s lots of chaos,
yelling on left side [of unit].”
30. 3.22.11 – DW
Pt running down hall yelling, punched female peer in face.
31. 03.22.11 – VJ Interview with UIC reviewers:
“I don’t feel safe in this hospital – too many fights, too much
arguing and kids cursing staff. I got in one fight here when
a boy kept taking book away from me. Staff didn’t do nothing,
so I pushed his hand and I hit him back. We fought.”
32. 03.22.11 – MD
Pt aggressive to staff, required STAT Thorazine 25 mg. IM.
Still agitated, needed multiple redirections.
33. 03.22.11 – GN Interview with UIC reviewers:
Pt reports he “doesn’t feel safe,” saying “kids try to fight me
all the time.” Admits to problems managing his own temper.
34. 03.25.11 – EM
Pt struck and threatened peer: “you’ll get fucked up dude”;
pt said, “he hit me first.”
35. 04.02.11 – KS
Pt observed in verbal altercation with peer, which escalated
to a physical confrontation. “She tried to throw her tray at me
so I threw my milk at her. Then she started hitting me (in my
head and shoulder). It doesn’t hurt though.”
36. 4/3/11 – SB
Nursing Note: “Pt was approached by peer in hallway who
punched her. Pt did not respond with physical aggression.”
37. 04.11.11 – MSM
Case manager met with pt about conflicts. Pt said one peer
messed with him, so he threw the boy on the floor. Pt said
another peer hit him in the head… and that turned into a fight.

10

 xxxxxxxxxxx
38. 04.13.11 – MSM
Pt disruptive to milieu. Provokes peers by calling names and
pushing them.
39. 04.15.11 – KT
Pt constantly disrupting group by hitting peer and yelling:
“shut up stupid ass.” Walked out of dayroom, very tearful.
40. 04.15.11 – TW Progress note by psychiatrist’s [name redacted]:
Note indicated that pt stated that yesterday her roommate set
a fire in their room; TW did not respond or stop her roommate.
41. 04.17.11 – TW
Pt observed punching peers in back while standing in line.
Redirected several times but refused to follow directions.
42. 04.18.11 – MD
Agitated with 1:1, flipped table, threw chairs, tried to strike
several staff. Slammed phone against wall, tried to take picture
off wall. To QR. 11:35 AM. pushed way into the nursing station.
Threw cup of water at staff, saying “I’m gonna hit you.”
43. 04.19.11 – MD
Pushed way into nursing station. “I’ll fucking kill you bitch.
I swear I will.” Placed in QR, stat IM.
44. 04.19.11 – KT
Pt unable to socialize with peers without staff next to him.
Extremely aggressive to others – pushes peers onto floor,
throws wood blocks at peers. Multiple TO’s in room.
45. 04.21.11 – DW
Nursing Note: “Pt was observed very agitated after one pt hit
another pt several times without provocation. PT then began
making statements such as “I wish he would have hit me!
He needed his ass kicked.”
46. 04.22.11 – MD [Note by UIC team member.]:
Arrive on Adolescent Girls Unit to see pt (MD) pounding on
dayroom windows, running into another pt’s room, cursing
loudly, staff following her around. By 10:35 AM pt was still
disruptive, running around dayroom.
47. 04.23.11 – LS
Pt called female peer “fat panda bitch”, then asked to take TO
outside dayroom. She then kicked other pt’s chair; hit female
peer, sent to her room to de-escalate.
48. 04.26.11 – DW
DW Nursing Note: “Pt involved in altercation with another pt
that results in DW being scratched with a pencil. After incident
pt said “I’m gonna go after him.”
49. 4/26/11 – AL Nursing Note:
Pt was sitting in dayroom during the community group when
struck by a peer with no obvious precipitating factors.

11

 50. 04.27.11 – AL Treatment Plan Review:
Pt recently punched by peer without reason; didn’t retaliate.
51. 04.27.11 – AH
Pt was provoking a peer by calling names since evening.
Pt tripped the peer in the day room; peer punched the pt.
52. 04.28.11 – MD
Pt jumped over nursing station, observed throwing objects
at peers in other wing. Escorted to room.
53. 04.28.11 – SD
Pt severely agitated and verbally threatening to staff after
threatening to jump over nursing station to “beat that nurse.”
Three staff tried to verbally deescalate, ending with pt jumping
over nursing station and trying to hit staff member. Escorted to
QR, received STAT Zyprexa 10 mg. IM.
54. 04.28.11 – KT
“T/O in hall x 3” for hitting peer; refused T/O, threw self on floor.
55. 04.29.11 – KT
Pt became aggressive, kicked staff. Refused p/o Zyprexa Zydis,
received 2.5 mg. IM.
56. 05.01.11 – MSM
Pt hit, kicked staff; tore down curtains.
57. 05.01.11 – AC
“I’m gonna kill you bitch.” Pt had plastic knife in sock to use
to kill staff. Throwing dayroom table, punching walls. QR.
58. 05.01.11 – TW
Threaten several staff; to QR when started pushing staff.
59. 05.02.11 – TW
Left dayroom without permission, agitated when redirected.
Assaulted staff by hitting and smacking staff members’ arms.
60. 05.02.11 – DJ
Pt in physical altercation in gym. Pt pushed peer (per staff)
and peer pushed him in return; pt pushed peer to the floor.
Pt has no injuries and no c/o pain.
61. 05.02.11 – LS
Patient had thrown a comb at a peer and ran into the hallway.
Staff escorted pt back to her room. Pt grabbed onto doorway,
struggled with staff, fell into wall and received bloody mouth.
Pt stated “staff pushed me toward the wall and my lip bumped
into the wall.” Mouth examined; small crack lip with bloody
oozing. Pressure applied and ice pack.
62. 05.02.11 – MD
Pt physically hit peer after peer severely provoked her.

12

 63. 05.03.11 – KT
Impulsive, very disruptive in groups, running around dayroom,
hitting peers, throwing balls, unable to stay seated, hyper.
64. 05.03.11 – DP
Pt approached peer from behind, put him in a headlock and
tried to choke him. Staff intervened and separated pts.
65. 05.03.11 – AC
Pt demanding a peer open dayroom door: “Open the door,
you fat bitch!” Pt was threatening peer: “I’ll beat your ass.”
Pt returned to dayroom and hit peer with the door; physical
altercation broke out. Pt has conflict with two peers on unit
west hall, which is unsafe for pt to remain... Team decision
to transfer pt to 2-S for her safety.
66. 05.03.11 – SD
Pt observed in physical altercation with peer, punching peer
several times. Pt and peer separated by staff after code yellow.
67. 05.03.11 – SD
According to charge nurse, pt got into the nursing station and
tried to attack her. Pt then hit by another pt, according to RN.
68. 05.03. – SH Progress note:
“Pt observed punching another peer.”
69. 05.04.11 – AH
Pt highly impulsive, provoking peers, pushing and touching
peers; he was asked to refrain from that behavior but kept on
feeding negative behaviors of peers who were instigating him
to fight. Not following staff directions; unexpectedly punched
peer in the face. Pt escorted to room.
70. 05.05.11 – DW
Pt punched peer in back of head with closed fist.
71. 05.06.11 – KT
Told staff, “I’m going to kill you bitch.” Given chance to relax
in room. Observed punching window, seen punching peers…
72. 05.07.11 –RS
Escorted to QR after physical altercation with peer; complained
th
of pain in right 5 finger, given Motrin.
73. 05.08.11 – SD
Pt provoking peers in hall by flashing gang signs. Pt stated
peer entered her room and scratched her face three times.
Pt punched a peer with stated intention to “kill her baby.”
Escorted to QR where she received 10 mg. Zyprexa IM STAT
for aggression and fighting.
74. 05.09.11 – SD
Pt became extremely aggressive to peer; engaged in physical
altercation with peer and was placed in QR.

13

 75. 05.10.11 – MO
Pt noted to strike peer’s left shoulder after peer provoked pt
and “swung” at her first.
76. 05.10.11 – SamH
Pt walked past peer’s room; became agitated when peer called
pt a bitch. Pt walked up and said “I’m already in a bad mood;
don’t fuck with me or I’ll beat your ass.” Staff stepped between
pt and peer, redirected pt to ignore negative comments of peer.
Pt reached over staff, grabbed peer out of room by her hair.
77. 05.14.11 – LM
Pt was provoking peers throughout shift. Cursing at them,
threatening to fight them. Encouraged pt to cease behaviors
and calm self. Pt struggled to comply. T/O. given in room.
Rejoined group; while sitting at table during second group
pt was approached by peer; hit by peer on left side of head
with closed fist. Laceration to head evident; bleeding and
1.5 cm cut. Dressing applied. Order from PA, sent pt to ER.
78. 05.15.11 – CP
Pt got angry with his roommate. Said roommate touched his
thing. Pt screamed, yelled and threatened roommate; tried to
jump on him but was stopped by staff. Pt was placed in DR
for tonight due to his aggression and history of SAO.
79. 05.17.11 – KT
Yesterday found choking roommate but when asked to switch
rooms became angry and assaultive toward staff.
80. 05.18.11 – CP
Following basketball game in gym, pt became agitated with
peer. Per pt, “he called me a bitch.” As pts were lining up to
get into elevator, pt hit peer.
81. 05.18.11 – CP Nursing Note:
Pt involved in a physical altercation with a peer at 10:30 AM.
already agitated and threatening. Pt was not re-directable.

Pt

Peer entered his room and punched him in the lip [causing
lip to bleed]. Peer was immediately removed from pt’s room.
Pt said: “I’m gonna fuck him up…I will fuck him up.”
82. CB Nursing Note about incident of 05.17.11:
“Pt has had multiple verbal altercations with peers and staff.
Pt became upset with one peer on 5/17 and attacked peer by
punching her in the face. Given special individual program.
83. 5/20/11 – CP
Restraint record noted “Sustained split lip from second incident.
Pt examined by nurse. Pt lip bleeding on R side. Given ice pack
and medical consult completed.
84. 05.20.11 – CP Progress Note
“Pt was asleep this shift due to receiving a PRN in day shift
for multiple fights.”

14

 85. 05.20.11 Note by UIC reviewers on boys unit:
“Upon arriving at 3-N we immediately noticed that all patients
were in their rooms, reportedly because of unprovoked attack
by a non-ward on a non-ward in the right-side dayroom. Nurse
was treating wound of the victim, who was bleeding above the
left eye. Noted 18 patients and only one staff in dayroom.”
•

During an interview in 3-N dayroom with DCFS ward (DG),
two non-wards seated nearby told the UIC reviewer about
their concerns for DG’s safety at Hartgrove, and they urged
that DG be sent “someplace safer.”
Both youths, who were bigger adolescents, explained to the
UIC reviewer that they had been “looking out” for DG (who is
small in stature) because he often “annoys and provokes
people,” which made him a target for attack.
Since both of these boys were going to be discharged from
the hospital within the next two days, they said, “there won’t
be anyone here to look out for him after we’re gone; you need
to get him out of here.”

•

At this point, a UHS administrator intervened, calling the
UIC reviewer out of the dayroom and telling her she could
not speak with patients who were not DCFS wards.9

•

When the UIC reviewer again examined DG’s chart the next
day, a special note was discovered:
“Pt denies ever feeling intimidated by peers or ever having
feelings of being unsafe. He denies ever verbalizing those
kinds of feelings to staff or peers.”

This curious note was entered following a meeting between
the UHS Hartgrove CEO and three UIC reviewers – including
Dr. Davidson and the UIC team member who had spoken with
DG and the two non-wards a day earlier; part of that meeting
focused on the DG interview and the safety concerns raised
by the two non-wards).
It would appear from the chronology of events, then, that
UHS officials thought it was appropriate to ask a mentally ill
and cognitively impaired child to essentially “vouch” for his
sense of personal safety in the hospital. Despite this rather
questionable endorsement of Hartgrove by this DCFS ward,
it should be reiterated that it was the two non-wards – not DG
himself – who feared for his safety and consequently took if
upon themselves to protect him.

9

In fact, the Illinois Mental Health Code unambiguously protects the right
of any patient in a psychiatric facility to “unimpeded, private and uncensored
communication with persons of [their] choice by mail, telephone or visitation”
[(405 ILCS 5/2-103) (from Ch.91 ½ par.2-103)].
Further, DCFS’ chief legal counsel indicated that the UIC reviewers could
speak with any non-ward who wished to speak with them, provided that
such conversations were initiated by the non-wards; since this has always
been the standard practice of the UIC team when conducting such reviews
on behalf of DCFS, we will continue to operate under this guideline.

15

 86. 05.20.11 – SD
Pt hit peer in face during gym; given Zyprexa 10 MG IM STAT
for physical aggression.
87. 05.21.11 – CP Progress note by psychiatrist [name redacted]:
“Pt was in 2 fights yesterday and continues to minimize his
role in escalating the situation. Pt reported that ‘peer was
calling me bitch, so I punched him.’”
“Then pt was attacked by 3 peers in retaliation. Pt was irritable
and was not participating in groups this morning. Pt continues
to lack insight about aggressive behavior and exhibits poor
judgment. Pt ruminates on DCFS releasing him to his mother.”
•

Note: CP’s IQ is reported in Master Treatment Plan to be 53.
The MTP also indicated “Problem: Mental Retardation or
Pervasive Developmental Delay. Problem Description: Mild
MR, per discharge summary in 2008.”

88. 05.21.11 – KT
Pt wanted to sit where peer was sitting; struck peer in face.
Peer struck him back and pt began to cry.
89. 05.23.11 – KT
1:1 at about 11 AM for impulsive and aggressive behaviors.
Not following directions, pt got agitated so was asked to leave
group... Tried kick staff. Did bite MHS; punched, head butted
writer as well.
90. 5/23/11 – CP
Pt arguing with peer; grabbed him by the neck, telling him:
“shut the fuck up talking to me.” Pt told to return to room,
then became agitated and started threatening and swearing
at staff.
Pt asked to talk to therapist to calm down. Pt redirected to
use coping skills to maintain impulsive behavior and to take
responsibility for actions.
91. 5/28/1 – CP
Pt was involved in a physical altercation with a peer…,
which became verbally aggressive due to their discussing
gang-related activities.
Peer called pt a “Bitch”; verbal confrontation escalated to a
physical confrontation. Pt was placed in a three-minute min
hold and escorted [to QR].
92. 06.11.11 – CG
While pt was walking in hallway when another pt punched him
in the left eye without any provocation. Pt’s left eye assessed;
nothing noted but ice pack applied over eye.
93. 06.12.11 – SL
Pt in DR sitting at table; another pt was kicking him under the
table. When pt stood up the other pt punched him in the head.
No apparent injury.

16

 94. 06.13.11 – JD
Pt was agitated by a peer who provoked him by throwing apple at
pt’s face; pt became assaultive and stated that “I’m going to
fuck him up…”
95. 06.14.11 – RK Interview with UIC reviewers:
Pt stated: “Kids here act up every day. There was a fight at
the end of the hall… one kid walked up behind another kid
and just started punching him in the dayroom, and then they
were fighting in the hall.”
96. 06.14.11 – SH
About 7:15 pm provoked by peer, inappropriate words. Met with
peer and was punched in the face, (causing swollen left eye);
they began fighting. Staff intervened and removed pt to QR.
Left swollen face and eye, given ice pack.
NOTE: Items 97–100 are temporarily redacted because they contain
information provided by confidential sources. The UIC reviewers
will discuss these incidents privately with the director and DCFS’
chief counsel, and the data will be summarized in the final report.
97. [NOTE by UIC team members.]
XXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
98. [NOTE by UIC team members.]
XXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
99. [NOTE by UIC team members.]
XXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
100. [NOTE by UIC team members.]
XXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Xxxxxxx

17

 III. Summary of general findings.

General Findings
by the UIC Reviewers
at UHS Hartgrove.

The cumulative weight of the available data regarding services
provided DCFS wards at UHS Hartgrove Hospital demonstrates
a consistent pattern of unacceptable risks of harm, substandard
quality of care, poor clinical treatment and discharge planning,
and questionable clinical management practices by hospital and
corporate officials at all levels of the organization.10 11
Moreover, the troubling findings of this report bring into sharp
focus the Department’s fiduciary duty of care to ensure that its
wards receive effective treatment for their mental health needs;
the implications for the long-term health of DCFS wards who
received treatment under the conditions described in this report
will therefore require ongoing scrutiny by the Department.
In the present case, longstanding quality of care deficiencies
involved some of the most basic aspects of clinical operations
and healthcare standards required of any hospital, suggesting
a critical failure of accountability by UHS corporate officials:
•

Specifically, it is clear that wards admitted to this hospital
routinely witnessed or experienced adverse events, often
in the form of violent assaults and a chaotic environment,
and that such experiences were inherently stressful and
emotionally traumatizing.

•

Whether as witnesses or victims, DCFS wards – many of
whom already suffer from the sequelae of Post-Traumatic
Stress Disorder as a result of previous childhood abuse –
are more likely to be vulnerable to experience increased
levels of subjective distress in reaction to such violent acts
occurring in a chaotic hospital setting.

•

Insofar as DCFS wards admitted to UHS Hartgrove were
exposed to the harmful iatrogenic effects of a dysfunctional
healthcare institution, their opportunity to receive needed
mental health treatment in a safe environment suffered as
a result of hospital-induced trauma.

10

UIC is not alone in documenting an array of quality of care problems at
UHS Hartgrove, as evidenced by a recent report from the federal Center
for Medicare and Medicaid Services, which found that senior medical and
nursing leadership “failed to provide adequate oversight” to ensure quality
of care, and that certain other clinical/administrative failures “resulted in a
lack of guidance to staff providing individualized and coordinated treatment,
potentially denying patients improvement and discharge from the hospital.”
11

Of interest, a number of the current UIC findings are also mirrored in
surveys conducted by CMS and state departments of public health at other
UHS facilities around the country. Further, the U.S. Department of Justice
recently took action in federal court regarding the failure of UHS corporate
officials to ensure adequate quality of care to children in a Virginia facility;
this and other relevant cases will be discussed below.

18

 Xxxxxxxxx XXXX

What did the UIC reviewers find at UHS Hartgrove?
While the UIC reviewers examined dozens of individual cases
of DCFS wards admitted to UHS Hartgrove Hospital, four of which
are discussed below, a consistent pattern emerged as the team
compared case review findings with available data about quality
of care performance, treatment team functioning and the apparent
clinical oversight problems within the hospital.
Furthermore, the consistent case-specific quality of care data
eventually led the UIC reviewers to examine broader evidence
about system-related quality failures that often exposed patients
to jeopardy and substandard care in the hospital, including:

 
  
 
  
Failures resulted in
lack of guidance to staff
… potentially delaying
patients’ improvement…
[and] exposed patients
to an unsafe environment
and unsafe care.

 
  

 
  

Report on UHS Hartgrove Hospital
by federal surveyors from the Center
for Medicare and Medicaid Services;
May 5, 2011.

 
  

•
•
•
•
•
•
•

Failure to protect patients from harm or risks of harm.
Failure to ensure a safe treatment environment.
Failure to ensure adequate staffing for patient care.
Failure to adequately train and supervise staff.
Failure to develop individualized treatment plans.
Failure to develop adequate discharge/aftercare plans.
Failure to conduct effective QAPI monitoring.

Report by federal CMS surveyors mirrors UIC findings.
Underscoring the quality failures identified by the UIC reviewers,
the federal Center for Medicare and Medicaid Services also found
parallel quality of care deficiencies during an unannounced 2011
survey at UHS Hartgrove. Moreover, the CMS report – obtained
by UIC reviewers through a Freedom of Information Act request
– reads like a catalog of organizational incompetence, with the
terms “failed” or “failure” appearing multiple times on 39 of the
document’s total 49 pages:
•

On page 6, for example, the CMS report identified “failures
[by clinical leadership of the hospital to ensure that
Master Treatment Plans were individualized], result[ing]
in lack of guidance to staff in providing individualized
and coordinated treatment, potentially delaying patients
improvement and discharge from the hospital.”

•

On page 30 the CMS surveyors noted that psychiatrists and
social workers were not developing adequate discharge plans
and aftercare recommendations, identifying this deficiency as
“a failure that compromises appropriate and timely followup care for patients.”

•

On page 33 the CMS report indicated that the “failures [by
hospital medical/administrative leaders to follow hospital
policies on investigating abuse and harm to a patient]
expose[d] patients to an unsafe environment and unsafe
patient care.”
19

 Xxxxxxxxx XXXX
While the UIC reviewers were not surprised to discover that many
of the findings by the federal CMS surveyors paralleled similar
evidence-based conclusions in the UIC report on UHS Hartgrove,
they were nonetheless taken aback by one particular section of
the CMS report that pointed to management accountability issues
surrounding harm to a 16-year-old boy seriously injured by staff
at the facility during May 2011.12

 
  
 
  
Review of policies [on
investigation of patient
abuse and neglect]
revealed [hospital officials]
failed to follow all of the
requirements outlined in
these policies.

 
  

Of special concern for DCFS, the CMS report indicated that UHS
Hartgrove officials: (a) failed to properly investigate this harmful
incident; and (b) deliberately ignored all of their own policies in
the process. More worrisome, however, CMS surveyors were led
to believe that the hospital had been unable to fully investigate
this incident because DCFS (and the Chicago Police Department)
had not provided them with the necessary information that would
have allowed the hospital to conclude its investigation.13
This misleading statement to federal CMS surveyors had the
effect of deflecting attention away from the clear failure by UHS
Hartgrove officials to protect patients from harm, but subsequent
interviews by the CMS surveyors with hospital administrators –
including the medical director, director of nursing and others in
senior management positions – were even more troubling:

 
  

Report on UHS Hartgrove Hospital
by federal surveyors from the Center
for Medicare and Medicaid Services;
May 5, 2011.

•

 
  

On pages 33-34 of the CMS report the medical director of
the hospital) was cited for “failure to monitor and evaluate
the quality… of services and treatment provided by the
medical staff… [and failure to ensure that an allegation
of patient abuse was adequately investigated.” 14

12

This case reportedly involved a fracture to the arm of a non-ward during
an inappropriate restraint; the CMS report was sharply critical of Hartgrove
officials for failure to document the incident or seek medical treatment for
the youth until the second day following his injury.
The UIC reviewers subsequently learned about this matter from confidential
hospital sources but were unable to examine any case materials or raise the
issue with UHS Hartgrove officials at that time since the youth was not a
ward of DCFS.
13

On pages 39-40 of the CMS report the following surveyor notes appear:
“During interview with the Director of Risk Management, Assistant Director
of Risk Management (Patient Advocate), and Director of Nursing on 5/23/11
at approximately 2:30 p.m. the investigation procedure used by the hospital
was discussed. The surveyor asked for the facility’s policy regarding
patient abuse and neglect. The facility eventually presented three
different policies to address allegations of abuse and neglect. Review
of the policies [by the surveyors] revealed the facility failed to follow
all of the requirements outlined in these policies.”

14

The CMS report added that “these failures expose patients to an
unsafe environment and unsafe patient care.”

20

 Xxxxxxxxx XXXX
•

 
  

On page 44 of the CMS report, the DON (director of nursing)
was cited for “failure to provide adequate oversight to
ensure quality nursing services… [including] failure to
ensure Master Treatment Plans identified patient-specific
nursing interventions.” 15 16
−

Also of interest, on page 37 the surveyors noted that:
“In the interview on 5/23/11… the Director of Nursing
stated that there was the possibility that the patient
[who was injured by staff] sustained the fracture
prior to admission to the facility.” 17

Further, among the most revealing acknowledgments that arose
during the interviews and document analyses conducted by CMS
is a comment in a hospital report, recording a meeting on 5/17/11,
appearing on a form identified by the surveyors (on page 41) as
“UHS BH [Universal Health Services Behavior Health].”
According to the CMS report, the document was part of the
investigation into the patient’s injury and listed contributory factors
that explained staff errors or problems documenting the incident
that occurred on 5/3/11 in a timely manner. One of the supposedly
contributory factors cited by Hartgrove officials was the “high level
of acuity on the unit due to the number of patients admitted from
juvenile detention.”

Elsewhere in the current report the UIC reviewers have raised
concerns regarding nursing and direct-care staffing levels on the
UHS Hartgrove units, pointing to the frequently chaotic milieu and
incidents of aggressive behaviors as indicators of chronic failure
by hospital officials to ensure a safe environment; this revealing
statement, however, confirms what staff had told the UIC team –
that high patient census often made if difficult to do their jobs.
15

The CMS report noted that: “This failure result[ed] in lack of guidance
for nursing staff in providing individualized and focused patient care,”
an issue that will be discussed below with regard to the case reviews of
DCFS wards.
 
  
16
The surveyors referenced federal regulations [42 CFR §482482.62(d)(1)]
regarding nursing services, as follows: “The director [of nursing] must
demonstrate competence to participate in interdisciplinary formulation
of individual treatment plans; to give skilled nursing care and therapy;
and to direct, monitor and evaluate the nursing care furnished.”
17

The CMS surveyors swatted this unusual statement aside by citing the
hospital’s medical records showing otherwise, noting that “a review of the
‘History & Physical Examination’ performed by a [Hartgrove] physician…
[found no evidence of prior injury but instead had recorded] ‘Extremities:
Symmetrical joints. No joint swelling. No joint effusions, Circulation is good...
Patient is able to move shoulders and clavicular area normally… Referral
for a more detailed examination is not necessary.’”

21

 Xxxxxxxxx XXXX
At the same time, the CMS surveyors managed to indirectly
confirm what the UIC reviewers had already determined about
treatment team functioning at the hospital: specifically, that the
treatment teams often appear to be little more than empty shells,
providing generic or boiler-plated treatment and discharge plans
that may serve a required paperwork function but offer limited
and ineffective clinical decision-making authority.

 
  

•

On page 42 of the CMS report, for example, the surveyors
reference “Policy No. PC 861 9a: Investigation and Report
of Abuse and Neglect Patients by Staff,” noting that this
policy stipulated that the “Charge RN/RN Supervisor [will]
consult with the treatment team, and attending physician
regarding the information that indicates abuse or neglect.”
However, the CMS report noted: “there was no evidence
in any of the written reports that showed the treatment
team was involved…” 18

Finally, and most important to reiterate, while the primary focus
of criticism in the CMS report related to a failure of medical staff
leadership – citing the medical director and director of nursing –
UHS Hartgrove officials essentially ignored this inconvenient fact
in their submitted plan of correction to CMS by putting the onus
for this massive quality failure on lower-level nursing managers
and direct-care unit staff. The implication of such misleading
“blame-shifting” is the suggestion that the bulk of the hospital’s
deficiencies can be cured by (a) additional training for line staff
or (b) another revision of the written policies and guidelines that
were previously ignored in actual practice.19
Such an implicit denial of management accountability does not
inspire confidence that either UHS’ corporate or hospital-level
leadership is willing to acknowledge the system-related quality
failures that have occurred at every level of this facility: medical
and nursing supervision; quality assurance and performance
improvement; risk management; treatment team functioning;
clinical documentation of patient care; staff training; and the
staffing of units to ensure patient safety and active treatment.

18

CMS surveyors also reviewed “Policy No. R1 -1.3.4,” which requires that:
"The Patient Advocate communicates patient's complaint/grievance to
the treatment team and together, determines the following appropriate
steps..." As in the previous instance, however, the CMS report found that
“there was no evidence in any of the written investigation reports that
showed that the treatment team was involved…”

19

The CMS “B-Tag” identifying this issue references 42 CFR §482.62(b)(2),
which has to do with medical staff leadership in healthcare facilities [noted in
the CMS report as Tag B-144, pages 33-44].

 
  
22

 Hospital-related findings by the UIC reviewers.
Apart from specific concerns about the clinical treatment and
quality of care provided to DCFS wards, the UIC reviewers
identified a number of general issues or problems related to
hospital functioning, some of which are discussed below.

 
  

 
  
 
  

•

Get rid of the cots,
quickly… IDPH is
in the building!

 
  

 
  

 
  

Sleeping patients on cots in hallways.
The UIC reviewers were reliably informed by confidential
sources that UHS Hartgrove officials had been routinely
exceeding its licensed bed capacity since 2007 in an effort
to maximize financial profit; this practice reportedly increased
in mid-2008 after DCFS placed an intake hold on Riveredge
Hospital. UHS Hartgrove officials seized that opportunity,
according to one reliable hospital source, to “jam as many
kids into the units as they could get away with.” 20
During the course of gathering data for the current report,
the UIC reviewers obtained copies of all surveys conducted
at UHS Hartgrove by the Illinois Department of Public Health
since 2008; the documents included an unannounced survey
conducted by IDPH in March 2009, reportedly after the
agency received a complaint about patients being slept on
cots when the hospital exceeded its official licensed capacity.
While the findings of the 2009 IDPH survey are revealing by
themselves, several UIC sources helped to frame the context
surrounding the arrival of the surveyors at the hospital:
o

First, the IDPH surveyors confirmed what the UIC team
had been told was occurring: examining a sample of the
daily census sheets for an approximate 90-day period from
12/3/08 to 2/28/09 [see attached IDPH report].
The hospital’s authorized capacity was 136 beds at
that time, but IDPH determined that the facility had
been over-capacity on 52 days (or 60% of the time)
during the 88-day sample period, on some days by
as many as 17 beds.

Photograph by UIC reviewers of rollaway cots
being moved onto elevator at UHS Hartgrove.

o

What the IDPH surveyors could not have known at the
time, of course, is that while they were in the first-floor
conference room examining the daily census records for
the hospital, the director of nursing was running through
the inpatient units frantically yelling orders at the staff to
“Get rid of the cots, quickly; IDPH is in the building!”

20

According to several hospital sources, DCFS wards as well as non-wards
were slept on movable cots in dayrooms, hallways and other areas of the
units because there were no vacant bedrooms available; the cots would then
be wheeled away in the morning to a storage room off of the gymnasium.

 
  
23

 xxxxxxxxxxxx
As amusing as the anecdote about the nursing director’s
frantic scurrying through the hospital units seemed when it
was first related to the UIC reviewers by staff members who
witnessed the event, it arguably speaks to the fact that senior
officials at UHS Hartgrove fully understood the implications of
the unannounced IDPH visit: specifically, that their decision to
“jam as many kids into the units as they could get away with,”
as one staff member put it, willfully ignored federal regulations
about patients’ rights to privacy as well as the right to receive
care in a safe environment.21

 
  

What was never amusing at all, however, was the fact that
over the course of several years hundreds of mentally ill
children – DCFS wards and non-wards alike – were slept
on rollaway cots in an overcrowded and frequently chaotic
psychiatric hospital so that UHS corporate officials could
take advantage of the opportunity to maximize profits.22 23

•

Inadequate staffing levels and staff supervision.
When specifically questioned about whether UHS Hartgrove
officials ever increased staffing levels to offset the sudden
influx of patients when hospital units exceeded authorized
bed-capacity, UIC sources indicated that this rarely occurred.
In effect, then, a de facto decrease in staffing ratios may
occur at certain times when patients flood into the units
beyond appropriate capacity.
Holding aside the issue of UHS Hartgrove officials inflating
hospital census whenever the opportunity arose, the more
immediate concern for DCFS ought to be whether the facility
provided adequate staffing levels under normal circumstances
of daily operation. 24

21

 
  

See 42 CFR § 482.13 (c)(1)(2).

22

 
  One DCFS ward told the UIC reviewers about waking up early on the
adolescent boys unit one morning and seeing a newly admitted patient
sleeping in a counselor’s office with his head on a pillow that had been
placed on the desk, apparently because there were no more cots. 
  

 
  

23

As for these frantic efforts to obstruct or mislead the IDPH surveyors –
who were at the hospital to conduct an investigation on behalf of the federal
Center for Medicare and Medicaid Services – the UIC team will leave this
matter for others to evaluate.

 
  

24

In this instance, “normal circumstances” refers to staffing levels on hospital
units when patient census is within limits that DCFS was led to understand –
based on previous representations by UHS officials – could be appropriately
managed by the available numbers of nursing and direct-care staff per shift.

24

 xxxxxxxxxxxx
Based on the available evidence, it is reasonable to conclude
that staffing levels at UHS Hartgrove are woefully inadequate
even under normal circumstances, and that patient safety and
quality of care have directly suffered as a result of corporatelevel decisions to minimize labor costs of facility operations:

 
  

o

UHS Hartgrove officials clearly indicated an awareness
of this issue when they reportedly told nursing managers
they would provide extra staff to the hospital units during
the course of the UIC review, the obvious intention being
to present a misleading impression that unit staffing levels
were higher than the usually scheduled pattern.

o

However, following the intake hold imposed by DCFS
on June 16 UIC reviewers immediately started receiving
text messages and emails from sources confirming that
staffing levels on the hospital units suddenly increased,
apparently as a direct result of the DCFS action.

o

UHS officials repeatedly stated to the UIC reviewers that
the facility typically maintains a staff-to-patient ratio of 1:5,
meaning the presence of one staff member to every five
patients on the day and evening shifts when therapeutic
programming activities are being conducted.25

Kids sexually assaulted
at hospital, report says.

 
  
A 13-year-old male patient
performed oral sex on a
15-year-old DCFS ward
in a dayroom crowded
with 14 other youths and
only one employee to
monitor them.

In fact, the UIC reviewers found evidence that Hartgrove
units have operated as low as 1:6 or even 1:7 at times –
as confirmed by direct-care staff who work on these units
– posing alarming safety risks under any circumstances.

 
  

o

Earlier in the current report it was noted that UIC reviewers
observed a single staff member alone with 22 patients in a
unit dayroom, a not infrequent occurrence of understaffing
by default (even if the 1:5 ratio was, technically speaking,
“scheduled-on-paper” on any given day).

o

Similarly, a few days earlier on that same unit, three boys
were left unmonitored by staff for 10-15 minutes, during
which time they engaged in sexual acting-out behaviors.

o

In September 2010 the Chicago Tribune reported on two
sexual incidents at Hartgrove, one of which clearly related
to understaffing: “A 13-year-old male patient performed oral
sex on a 15-year-old DCFS ward in a dayroom crowded with
roughly 14 other youths and only one hospital employee to
monitor them, records show. The worker said he was distracted
by trying to defuse a ‘conflict’ among other youths in the room.”

25

To place such numerical ratios in perspective, DCFS requires a staffing
level of 1:3 – 40% higher than the 1:5 ratio at UHS Hartgrove – for certain
residential treatment providers, suggesting that many of the violent incidents
and other behavior management problems observed at UHS Hartgrove are
directly related to gross understaffing of the hospital’s units.

25

 xxxxxxxxxxxx
Staffing levels in psychiatric hospitals. In a previous report
to DCFS regarding another Chicago Area psychiatric hospital,
the UIC reviewers discussed the issue of determining when
staffing levels are so inadequate as to undercut treatment
and endanger patient safety:26

 
  

Despite federal regulations that ambiguously require
psychiatric hospitals to have sufficient numbers of
staff to ensure patient safety and treatment, the UIC
team would readily acknowledge that this remains
an “eye of the beholder” matter in certain respects
– a problem complicated by the fact that Illinois is not
one of the few states that have attempted to define
what the term “adequate staffing levels” might
actually look like in practice.
That said, there are reasonable approaches to determining what can be considered adequate baseline
staffing for psychiatric units in various hospital and
residential settings, taking into account critical issues
of unit acuity, staffing mix and program leadership.
Most relevant, the American Academy of Child &
Adolescent Psychiatry weighed in on this discussion
nearly 20 years ago – with its Model for Minimum
Staffing Patterns for Hospitals Providing Acute
Treatment for Children and Adolescents with
Psychiatric Illnesses – putting the vague federal
regulations about sufficient numbers of qualified staff
into measurable categories related to case workloads
and hours necessary to accomplish essential clinical
care of patients.

The earlier UIC report to DCFS noted that AACAP’s model
guidelines identified specific minimum staff ratios to ensure
effective treatment and quality of patient care:
o

A 1:3 staffing ratio (or three staff to nine patients,
maintaining this ratio as unit size increases, up to a
maximum of 24 patients per unit).

o

One psychiatric nurse per shift for each 12 patients
(adjusted upward for acuity as necessary).

By comparison, the 1:5 staffing levels supposedly maintained
by UHS Hartgrove are 40% less than AACAP’s guidelines –
and even lower when considering such factors as units going
over-capacity or staff being pulled from the floor for “training”
(see discussion of training issues in the following section).
26

Review of Streamwood Hospital, prepared for the Illinois Department of
Children and Family Services by the UIC Mental Health Policy Program;
originally submitted in 2009, with a follow-up report in 2010.

26

 Xxxxxxxxx XXXX
Understaffing of the UHS Hartgrove units comes into even
sharper focus, however, when contrasted with the minimum
1:3 staffing ratios that DCFS requires of residential treatment
agencies that serve certain “severe” clinical populations of
mentally ill and/or behaviorally disordered youths.

 
  

Simply stated, the types of DCFS wards who are frequently
admitted to psychiatric hospitals during acute crises are,
paradoxically, often being sent from residential settings with
a 1:3 staffing ratio to a hospital with a 1:5 (or even lower)
staffing ratio. Worse, in the case of UHS Hartgrove, it is likely
DCFS wards will experience a counter-therapeutic hospital
milieu even more chaotic than the better-staffed residential
programs that were unable to manage their behaviors.
There is no great mystery to this bizarre paradox, of course,
other than the fact that the Department has certain legally
binding contractual relationships with its residential providers
that it does not have with psychiatric hospitals. DCFS can
therefore hold residential agencies directly accountable to
quality of care standards in ways that it cannot exercise with
regard to psychiatric hospitals serving the very same clinical
population of its wards.
With regard to the issue of UHS Hartgrove’s 1:5 staffing ratio,
then, the only tool available to the Department – absent the
sort of contractual screwdriver it has with residential agencies
– was the blunt instrument of an intake hold when it learned
on June 16 that its wards were being subjected to harm and
substandard care in this hospital; the Department made the
right call.
In responding to that decision, UHS Hartgrove officials will
presumably argue – as they have when confronted by UIC
reviewers about understaffing of the hospital units – that the
current 1:5 staffing levels are adequate, and they will likely
add that nursing administrators are authorized to temporarily
increase unit staffing whenever “patient acuity” issues arise.
DCFS should reject any such response as simply not credible,
especially in light of the evidence contained in both the UIC
and CMS reports that UHS officials have knowingly provided
substandard quality of care and placed children at risk of harm
whenever they believed that no one was watching. 27
27

In the section on corporate accountability, below, the UIC reviewers will
also examine the evidence of systemic understaffing and substandard quality
of care in other UHS hospitals around the country, with particular focus on
actions initiated against this corporation by the U.S. Department of Justice
and the Center for Medicare and Medicaid Services; also of interest are the
recent actions taken by several state child welfare agencies in regard to
harm to children in UHS-operated residential treatment centers.

27

 xxxxxxxxxxxx
•

However, a problem arises when such corrective measures
are phrased in a way that administrative accountability for a
massive and longstanding quality failure is implicitly shifted
onto lower-level nursing managers and direct-care unit staff
– the implication being that the hospital’s deficiencies will be
cured by simply mandating more training for staff. In effect,
UHS officials are offering a modified Casablanca Defense –
essentially purporting to be “shocked” to discover that the
Hartgrove staff are so poorly trained, then proposing that
the solution is to have staff re-trained by the same hospital
administrators who were responsible for the failed oversight
of the deficient and ineffectual training process for years.

CMS report on UHS Hartgrove.

 
  

 
  

More to the point, what is obscured in the corrective action
response of UHS officials to the CMS findings is the nature
of the repeated and willful failure by UHS officials to ensure
that their staff were properly trained and supported in critical
areas related to patient safety and quality of care.

 
  
A second restraint and
seclusion training will be
conducted for all mental
health specialists...

 
  

Inadequate staff training and hospital oversight.
As indicated above, UHS Hartgrove officials responded to the
recent CMS report by proffering corrective action measures
weighted heavily toward improving staff training and oversight
of significant areas of the hospital’s clinical and administrative
functioning. Having spent considerable time observing how
this hospital actually works on a daily basis, the UIC reviewers
would certainly applaud any forthright efforts to improve the
quality of patient care and clinical services at UHS Hartgrove.

Specifically, the UIC reviewers learned from UHS Hartgrove
staff that hospital officials were misrepresenting training data
about what is arguably the most critical area of patient safety
and behavioral management: the use of restraints.

 
  

o

Corrective action proposal made
by hospital officials in response to
report by Center for Medicare and
Medicaid Services; May 5, 201

Thus issue was initially brought to the attention of the
UIC team by a text message from a hospital staff member
saying that his/her “recertification class” in CPI restraint
training was “once again conducted in only one hour,”
even though the CPI program requires a minimum of three
to four hours every six months or annually.
According to the UIC source, all of the hospital staff who
attended the class that afternoon – as well as previous
restraint recertification classes – were issued certificates
“falsely indicating [they] had completed a full 3-hour
CPI recertification training.” 28

28

The sender of the text message stated that the one-hour recertification
session that afternoon only covered two restraint holds, and then only in a
“perfunctory” manner” with no “hands-on practice,” which was of little value in
helping staff understand how to avoid injuring patients during physical holds.

28

 xxxxxxxxxxxx
o

The UIC reviewers subsequently verified the information
about the questionable CPI recertification training during
interviews with other UHS Hartgrove sources over several
months, all of whom corroborated the basic points that:
(a) they received less than one hour of training; and (b)
they were then issued certificates indicating they actually
received either three or four hours of CPI recertification.
Copies of two such recertification cards, indicating threeor four-hour CPI training sessions, are displayed on this
page in the left column. The UIC reviewers also obtained
copies of sign-in sheets for all recertification classes from
2009-2011, one of which is shown on the following page.

Certificates issued by UHS Hartgrove
showing CPI recertification training was
conducted in three/four-hour sessions.

o

UIC sources indicated that these training certificates are
placed in the employees’ personnel files and in hospital
records used to demonstrate compliance with federal
requirements for reimbursement under Medicare and
Medicaid regulations.29 30

o

As if this matter could not get any worse, the UIC team
subsequently learned that staff attending these training
sessions were also routinely given the answers for the
“post-test,” thereby allowing UHS officials to assure any
third-party reviewers – whether UIC, DCFS, IDPH, JCAHO
or CMS – that all hospital employees had demonstrated
competency in this critical area of patient safety.31

29

See 42 CFR § 482.13(f)(4): “Training documentation. The hospital must
document in staff personnel records that training and demonstration of
competency were successfully completed.”
 
  
30
See also 42 CFR §§ 482.13 (e)(5) & (f))6): “All staff who have direct
patient contact must have ongoing education and training in the proper
and safe use of seclusion and restraint application and techniques…”
31

Despite assurances by UHS officials in their corrective action proposal
to CMS that “competency for all attendees [in staff training sessions] will be
measured by a post-test with a score of 90% or greater,” hospital sources
told UIC reviewers a different version:
o

“Questions for the CPI recertification test were oral,” according to
one staff member, “so one person would read the question out loud,
anyone can state the correct answer, and then everyone wrote the
correct answer on their individual test sheets.”

o

Other employees confirmed that trainees were told how to answer
test questions in various ways, including the trainer announcing that
he/she was stepping out of the room for 20 minutes but leaving the
CPI training manual with the correct test answers open on the desk,
saying to trainees: “You know you’re not supposed to look.” When
asked by a UIC reviewer if anyone ever looked, one hospital staff
member laughed and said: “We knew we were supposed to look.”

29

 Xxxxxxxxx XXXX
o

 
  

The UIC reviewers obtained copies of sign-in sheets for
more than 100 CPI recertification classes between 20092011, one of which (dated 11/19/09) is shown below; the
signature on line 4 of the second page belongs to one of
the two UHS Hartgrove staff members who were recently
fired as a result of the incident described in the 2011 CMS
report regarding the patient whose arm was fractured
during an inappropriate restraint.
When this former staff member was interviewed in August
2011 by the UIC reviewers, he indicated that neither of the
CPI classes that he attended in 2009 or 2010 lasted more
than one hour, nor was there any hands-on practice during
the classes of CPI-approved restraint holds.32
Further, when questioned about how the post-tests were
administered, he recalled that trainees were provided with
the correct answers to write down on the test sheets. At
the end of both classes, the former employee said, he was
given a CPI card attesting that he was provided four hours
of training, adding that he still retains those cards.33

32

CMS surveyors also interviewed this staff member in May 2011, although
they had no way of knowing at that time that many UHS Hartgrove staff may
have been improperly trained and certified in the use of restraints.
 
  
33
Note that the sign-in roster above contains a printed statement that the
“formal refresher course [requires a] minimum 3 hours.”

30

 Xxxxxxxxx XXXX
o

 
  

During an interview with the UHS regional vice president
and the UHS Hartgrove Hospital infection control nurse,
who also serves as the primary CPI trainer for the facility,
the UIC reviewers asked for copies of all policy guidelines
related to initial CPI restraint training as well as any annual
recertification training classes.
Among the documents that were provided was the chart
shown below indicating that UHS Hartgrove provides a
“CPI 4-hour recertification annually.”

31

 Xxxxxxxxx XXXX
o

 
  

When asked to describe how the recertification courses
were conducted at Hartgrove, the CPI trainer provided
a copy of the actual CPI recertification training booklet,
which includes graphics and illustrations demonstrating
appropriate restraint holds that should be part of any
recertification class.34
The CPI trainer told the UIC reviewers that recertification
classes taught at UHS Hartgrove allowed all the trainees
hands-on practice of the restraint holds illustrated in the
training booklet, adding that the classes were offered in
the required 3-hour minimum blocks of training time. UIC
sources who attended the recertification courses, however,
reiterated that the sessions were only one-hour and failed
to allow much, if any, hands-on practice of restraint holds.35

34

Illustrations of copyrighted CPI recertification training booklet reproduced
with the permission of the Crisis Prevention Institute.

35

The initial CPI training is supposed to involve a minimum 8-hour class,
although UIC’s sources at the hospital indicated that new employees at UHS
Hartgrove have sometimes been given the CPI introductory training in as
little time as four to six hours.
32

 Xxxxxxxxx XXXX

Table 2.

o

CPI compares “alignment”
with federal regulations on
restraint training specified
in 42 CFR § 482.

The Crisis Prevention Institute – which authorizes the use
of the CPI restraint methodology to psychiatric hospitals,
residential treatment programs, schools and other types of
institutions – has produced a series of comparative charts
showing how elements of CPI “align” with various guideline
or regulatory requirements: JCAHO, COA, CARF, CMS, etc.
The comparative CPI chart reproduced below would likely
lead CMS surveyors to conclude – absent evidence to the
contrary – that UHS Hartgrove was appropriately training its
staff in alignment with all requirements of 42 CFR § 482.13.

Medicare & Medicaid Programs:
Hospital Conditions of Participation
[42 CFR Part 482]

CPI Nonviolent Crisis Intervention
Instructor Certification Program

(f) Standard: Restraint or seclusion: Staff
training requirements. The patient has the right
to safe implementation of restraint or seclusion
by trained staff.

CPI has been training professionals to manage
disruptive and assaultive behavior since 1980.
CPI has an internationally recognized program
providing training in verbal de-escalation
strategies and safe restraint techniques.

(1) Training intervals. Staff must be trained
and able to demonstrate competency in the
application of restraints, implementation of
seclusion, monitoring, assessment, and
providing care for a patient in restraint or
seclusion—

CPI’s Nonviolent Crisis Intervention® training
program focuses on verbal intervention and
recommends physical intervention only as a
last resort. Certified Instructors must complete
competency-based testing in the application
of restraints and are trained to administer
competency-based testing to their own staff
in the safe use of restraints.

(i) Before performing any of the actions
specified in this paragraph;
(ii) As part of orientation; and
(iii) Subsequently on a periodic basis
consistent with hospital policy.

 
  

 
  

(2) Training content. The hospital must require
appropriate staff to have education, training,
and demonstrated knowledge based on the
specific needs of the patient population in at
least the following:
(i) Techniques to identify staff and patient
behaviors, events, and environmental factors
that may trigger circumstances that require the
use of a restraint or seclusion.

(ii) The use of nonphysical intervention skills.

CPI also provides resources for Certified
Instructors to offer refresher training, which
is recommended every six months, or a
minimum of once per year. Refresher
Workbooks, Leader’s Guides, and selfassessment tools for employees are available
through CPI. Those who complete refresher
training receive an updated certification card
from CPI.
Specific needs and behaviors of a given
population can be addressed throughout the
training program through examples. In particular,
the population’s needs and behaviors are
described and addressed in these ways: how
anxiety may be manifested by this population,
common defensive behaviors, factors which may
precipitate acting-out behaviors, specific issues
to consider in physical restraint, and ways to reestablish rapport following a crisis situation. Each
of these areas is addressed in the program with
reference to the population of individuals being
served.
The emphasis in Nonviolent Crisis Intervention®
training is on the prevention of situations that
may require the use of physical restraint. The
core of the program is the Crisis Development
Model SM, which provides staff with multiple
opportunities to intervene before a situation
arises which necessitates the use of physical
restraint and/or seclusion.

33

 Xxxxxxxxx XXXX

Table 2, continued. 36

 
  
 
  
 
  
 
  
 
  
 
  

Medicare & Medicaid Programs:
Hospital Conditions of Participation
[42 CFR Part 482]

CPI Nonviolent Crisis Intervention
Instructor Certification Program

(iii) Choosing the least restrictive intervention
based on an individualized assessment of the
patient’s medical, or behavioral status or
condition.

Nonviolent Crisis Intervention® training
emphasizes the importance of choosing the
least restrictive intervention. The focus of the
program is on verbal intervention, and physical
intervention is taught only as a last resort when
an individual is a danger to self or others.
The Instructor Manual provides information on
how to monitor a person in restraint, including
how to recognize and respond to a person in
physical and/ or psychological distress. CPI
recognizes the danger inherent in any restraint,
teaches that restraints must be used for the
shortest amount of time possible, and teaches
participants how to recognize when restraint is
no longer necessary.

(iv) The safe application and use of all types of
restraint or seclusion used in the hospital,
including training in how to recognize and
respond to signs of physical and psychological
distress (for example, positional asphyxia);
(v) Clinical identification of specific behavioral
changes that indicate that restraint or
seclusion is no longer necessary.

(vi) Monitoring the physical and psychological
well-being of the patient who is restrained or
secluded, including but not limited to,
respiratory and circulatory status, skin
integrity, vital signs, and any special
requirements specified by hospital policy
associated with the 1-hour face-to-face
evaluation.

Nonviolent Crisis Intervention® training stresses
the importance of having a monitor present at
every restraint—someone who is not involved in
performing the actual physical hold. The person
should be assigned the responsibility of monitoring physical signs of distress and obtaining medical assistance. All Certified Instructors receive
vital information in their manuals regarding
monitoring for signs of distress.

(3) Trainer requirements. Individuals providing
staff training must be qualified as evidenced by
education, training, and experience in
techniques used to address patients’
behaviors.

CPI trains Certified Instructors, who, in turn, may
train the participants within their facilities (trainthe-trainer program). CPI can assist Certified
Instructors in developing competency-based
evaluations based on the standards articulated
by specific states or regulating bodies. Such
evaluations include, at a minimum, a written
test, as well as direct observation of participants
deploying intervention skills.

(4) Training documentation. The hospital
must document in the staff personnel
records that the training and demonstration of competency were successfully
completed.

CPI issues Certificates of Completion to
participants who attend our training
programs. When a participant completes the
Four-Day Instructor Certification Program
(train-the-trainer program), that participant
becomes a Nonviolent Crisis Intervention®
Certified Instructor and is authorized to teach
staff at his or her place of employment.
Staff trained by a Certified Instructor are
issued wallet-size cards indicating that they
have been trained in the Nonviolent Crisis
Intervention® program.
In order to maintain their certification, Instructors
are required to provide documentation with
regard to trainings conducted at their organization. Copies of these records can be used to
document staff training in staff personnel
records.

36

NOTE: See http://www.crisisprevention.com/Resources/Alignments for this
and similar alignment charts, including one for JCAHO. x

 
  
34

 Xxxxxxxxx
o

 
  

In light of abundant indicators of questionable practices
involving staff training, the corrective actions cited below –
written by UHS officials in response to the 2011 CMS
findings about harm to a patient during an inappropriate
restraint – lack credibility with regard to organizational
competency to implement these proposed changes:
“The training content was reviewed and approved
6/13/11 by the CMO, CNO, and nursing leadership.”
Nurse managers, program specialists, and house

supervisors were reeducated on restraint and
seclusion policy, documentation requirements
verbal de-escalation, and avoidance of power
struggles. Training was conducted by CEO,
CNO, DCS, and DSO”
“A second restraint and seclusion training
will be conducted for all mental health
specialists. Training will be conducted by
CNO, Director of Staff Development, or
designee. Competency for all attendees
will be measured by a post-test with a
score of 90% or greater.”
o

As a paperwork exercise, this sort of corrective action
response shares much in common with the boiler-plated
treatment plans that were identified in the CMS report,
especially since both sets of documents are intended
to provide the appearance of compliance with normative
standards regarding quality of care.
What ordinarily characterizes hospitals that actually are
in compliance with such normative standards, however,
is that they do not require remedial education about the
most basic elements of hospital functioning – especially
subject matters as fundamental to quality of patient care
as treatment planning and staff training.

o

Indeed, the corrective action proposals to CMS appear
to be premised on the idea that UHS Hartgrove officials
were completely unaware of just how poorly their facility
was performing until federal surveyors showed up one day
to conduct an unannounced visit – and that notion by itself
strains credulity.
In fact, the UIC reviewers found frequent references in
hospital records from as early as 2008 – including notes
from the medical executive committee and performance
improvement committee, as well as email memos between  
  
35

 Xxxxxxxxx XXXX
corporate officials and hospital administrators – indicating
that there was awareness at senior corporate and hospital
levels about deficiencies in many of the quality of care and
clinical services areas later identified by CMS and UIC.
-

In a 2009 memo, XXXXX XXXXXX, UHS’ corporate
VP for clinical services informed the UHS Hartgrove
CEO that her recent site visit found that “treatment
plan updates [did not] address progress toward
treatment goals.”

-

The corporate VP also noted that: (a) “discharge
planning was not evident in medical records”;
(b) psychiatrists were not completing the admission
forms [PAFs] as stipulated by CMS rules; (c) “use
[and documentation] of mechanical restraints
is a continued concern”; (d) staff were holding
patients to administer emergency IM medications
but were apparently not reporting this practice in
medical records as physical restraints (thereby
underreporting actual restraint usage in the facility
as well as violating CMS rules).

-

Within UHS Hartgrove, subsequent minutes of the
performance improvement council referenced the
March 2009 site visit by the corporate VP, noting that:
“Seclusion and restraints may be underreported
(i.e., holding for IM medication is [still] a hold and
should be reported as such).” This is followed by
a corrective action recommendation involving the
“re-training [of] staff to recognize all forms of
restriction.”

-

In that same 2009 Performance Improvement Council
document another section indicates problems with the
development of individual treatment plans, concluding
with the recommendation that hospital officials will
“Review [MTP] form to encourage individualized
documentation of goals…,” and will “train nurse
managers and program specialists.”

-

Of most interest, this 2009 PI report also identified
problems in documentation of discharge plans by the
social workers as well as unspecified documentation
shortcomings by the psychiatrists; not surprisingly, in
both cases the identified administrative solution is to
“train [the social workers and psychiatrists] to
include more details in their documentation.”

 
  

xxxx XXXX
36

 o

From the standpoint of basic organizational accountability,
there is something quite remarkable and disturbing about
the issues identified in these hospital documents:
-

 
  

On the one hand, a senior UHS corporate-level official
discovered significant areas of quality failures involving
deficiencies in medical record documentation and
quality of patient care at UHS Hartgrove in early 2009
– all of which, it should be remembered, were later the
subjects of identical findings by CMS and UIC in 2011.
Inasmuch as this memo from the corporate-level VP
identified glaringly obvious quality failures at Hartgrove,
UHS earns partial credit for recognizing reality.

-

On the other hand, local-level hospital administrators
responded to this corporate memo with the same type
of generic and boiler-plated solutions about re-training
staff that were recently proffered as corrective action
to satisfy CMS, a response that seems quite detached
from reality in light of the evidence.

-

Further, since the UIC team discovered no follow-up
memos in the files from UHS-corporate instructing the
Hartgrove officials to go back to the drawing board,
it does not seem unreasonable to conclude that those
responsible for corporate-level oversight mechanisms
found such boiler-plated and ineffectual plans to be
entirely acceptable corrective action measures.

While DCFS should be concerned about the safety of its
wards in any hospital where major quality failures occur,
UHS Hartgrove is quite unique: in this case, the records
show a leadership so ineffectual that the best corrective
action it can formulate is to “encourage” its psychiatrists
and social workers to “individualize treatment plans”
– as if the task of ensuring nationally accepted standards
of professional care, to say nothing of federal healthcare
regulations, are merely optional suggestions.
UHS officials apparently saw no irony in proffering such
failed strategies to CMS as a workable corrective action
response in 2011. Regrettably, the available evidence now
points to a troubling pattern of deceptive practices behind
the failed strategies as well. In the meantime, hundreds of
DCFS wards who were admitted to UHS Hartgrove under
these troubling conditions have experienced unacceptable
consequences of a protracted quality failure.37 
  
37

Federal healthcare regulations require scrutiny of “basic hospital functions”
by a data-driven QAPI program as the primary mechanism to monitor quality
of patient care, making the protracted failure by UHS officials to remediate
these problems all the more deplorable. [See especially: 42 CFR § 482.21.]

37

 Xxxxxxxxx XXXX
•

 
  

Failure to report incident of unit staff drinking on duty.
The UIC reviewers were reliably informed by hospital sources
about an incident that occurred on the adolescent boys unit
on Saturday, July 9, involving two Hartgrove staff members
who were discovered to be drinking on duty.
o

One of the staff members was the unit’s charge nurse,
meaning that she was responsible for: (a) supervision
of all of the staff who were working the unit at that time;
and (b) setting up and/or administering psychotropic
medications to all of the children who were hospitalized
on the unit that day, some of whom were DCFS wards.

o

UIC sources reported that security cameras captured
images of the charge nurse and another hospital staff
member drinking liquor (reportedly Courvoisier) out of
a Styrofoam cup in the middle of the nursing station at
approximately 1:30 PM.

o

At some point a social worker is seen coming into the
nursing station; the social worker is then seen being
offered the cup by the charge nurse; the social worker
sniffed the cup, made a face, but did not take a drink.

o

Shortly afterward, the social worker left the unit nursing
station and reportedly called her supervisor to report
what she had just observed.
This initial telephone call apparently set off a series of
calls up the hospital’s administrative chain of command,
culminating with the UHS regional vice president (and
former CEO of Hartgrove) finally ordering the hospital’s
supervisor on duty to remove the nurse from the unit
– a process that reportedly took four to five hours.
Both the charge nurse and the second staff member
were fired on July 11, two days following this incident,
according to UIC sources at the hospital.

o

The UIC reviewers later learned that the charge nurse
worked a double-shift on that afternoon and was not
removed until approximately 6 PM, indicating that she
had by that point continued serving in her critical role
– including setting up and/or administering medications
to children on the unit – for between four to five hours.

Holding aside the sluggish administrative response in getting this
nurse off the unit, the potential risk of child endangerment ought
to have prompted UHS officials to notify DCFS about this matter;
however, there is no record of any hotline report from Hartgrove
through July 31, despite the fact that DCFS wards likely received
medications from a nurse who was fired for drinking on two shifts.
38

 xxxxxxxxxxxxx

Treatment planning and clinical issues.
Apart from serious behavioral management failures in a number
of the cases examined below, a review of treatment plans and
other clinical documentation at UHS Hartgrove Hospital indicated
a perfunctory approach, at best, to the critical task of formulating
effective treatment strategies; this shortcoming extended to the
development of clear treatment guidelines for direct-care staff
working with these difficult patient.38

 
  

•

More importantly, treatment plans, psychiatric progress notes
and other areas of clinical care are so woefully deficient as to
raise questions about the competence of the hospital’s clinical
and administrative leadership to ensure minimally acceptable
quality of care standards for DCFS wards.39

•

The UIC reviewers are not alone in taking such a critical view,
as evidenced by the findings of a recent unannounced survey
conducted by the federal Centers for Medicare and Medicaid
Services – discussed elsewhere in this report – which came
to virtually identical conclusions as the UIC team about a
range of quality of care deficiencies at UHS Hartgrove.40

38

Attention is drawn in particular to federal healthcare regulations [see
especially 42 CFR §482.61(c) and §482.61(d)] requiring all psychiatric
hospitals to ensure that patients are provided treatment plans that meet
long-established standards of care; other federal requirements [including,
for example, §482.24 (c) (1)) (i)], regarding the completeness of medical
records, are also relevant to the discussed below.

 
  

39

Of special interest, for example, the following progress note was recently
written by an attending psychiatrist regarding the behavior of a DCFS ward,
CP, who had been identified as having an IQ of 53:
“Pt was in two fights yesterday and continues to minimize
his role in escalating the situation. Pt reported ‘peer was
calling me bitch, so I punched him… Then pt was attacked
by three peers in retaliation… Pt continues to lack insight
about aggressive behavior and exhibits poor judgment..”
Note: CP’s IQ level of 53 is clearly reported in the Master Treatment Plan;
the current MTP also indicated “Problem: Mental Retardation or Pervasive
Developmental Delay… per discharge summary in 2008.”

 
  

40

Of particular relevance for this section, the federal CMS surveyors also
found unacceptable deficiencies regarding the adequacy of clinical treatment and discharge planning, among other serious problems at UHS
Hartgrove that were identified by the UIC reviewers.
Moreover, federal and state healthcare surveyors in other states identified
similar problems in UHS-operated hospitals across the U.S., indicating a
pattern of corporate-wide quality of care deficiencies, as will be discussed
further in the section on corporate accountability.

39

 X

•

 
  

Among the serious quality of care deficiencies identified by
the UIC reviewers are some of the most basic elements of
clinical performance for psychiatric hospitals:
−

Treatment plans are typically generic, non-individualized
and lacking indicators that treatment goals are adequately
reviewed and modified as necessary.

−

Psychiatrists’ progress notes are often unrelated to any
treatment goals, nor do they contain precise information
regarding patients’ measurable progress toward goals.41

−

Similarly, nursing progress notes – while descriptive of
patients’ behaviors manifested on the unit – are equally
disconnected from the requirement to indicate precisely
how staff are assisting patients to achieve therapeutic
goals set by the treatment team.

−

Discharge/aftercare planning is generally inadequate to
address ongoing treatment needs of patients, including
risk factors that may have precipitated hospitalization.42

−

Finally, treatment documentation was often found to reflect
gratuitous negative judgments/attributions about patients
that were lacking in clinical foundation or were unrelated
to supposed treatment goals, as can be seen in the four
individual case reviews in the following section.

41

As indicated elsewhere in this report [see Table 3, below] certain UHS
Hartgrove psychiatrists were observed to be typically spending as little as
three or four minutes a day talking with individual patients on the units.
When UIC reviewers subsequently examined the psychiatric progress notes
in patients’ charts, it was found that attending psychiatrists often failed to
indicate (by checking the appropriate boxes on the printed form) the type
of service that was rendered; each box includes a 5-digit billing code related
to the complexity of the particular service rendered – such as high, medium
or low complexity – meaning that it is almost impossible to rely upon such
inadequate documentation to gauge the intensity of treatment or the amount
of time that psychiatrists spend with patients.
With regard to Case # 1, for example, on every day from the time of this
patient’s admission through his discharge from the hospital the attending
psychiatrist wrote brief progress notes that appeared to do little more than
repeat observations previously charted by unit nursing staff; in none of the
progress notes was there any indication of (a) the amount of time that the
psychiatrist spent with this patient or (b) the specific clinical services that
were rendered on any of those dates.
42

As previously indicated, a 2009 site visit from the UHS corporate VP for
clinical services found that “discharge planning was not evident in medical
records,” something the CMS and UIC teams both agreed upon in 2011.

40

 X

•

Clinically unsophisticated notes and worthless comments are
typically found throughout the UHS Hartgrove clinical records,
including the following patient assessments:
−
−
−
−
−
−

 
  

“Patient refused to de-escalate”;
“Staff encouraged patient to not be agitated”;
“Patient has no insight into her negative behaviors”;
“Patient is unable to take responsibility for her actions”;
“Patient refused to use his coping skills...”
“Patient continues to lack insight about aggressive
behavior and exhibits poor judgment.” 43

The sheer volume of such statements in the clinical records
suggests that the hospital’s clinical/medical leadership either:
(a) never bother to read what their staff are writing about
patients; or (b) see nothing inappropriate about such remarks.
More to the point, while such countertherapeutic comments
– likely written more out of clinical ignorance than any overt
hostility toward mentally ill children – offer no clinical value
toward advancing the best treatment interests of individual
patients, they may serve to explain why the inpatient units
at this hospital are so frequently chaotic and out-of-control:
simply stated, it would appear that direct-care and nursing
staff at UHS Hartgrove Hospital lack some very rudimentary
therapeutic skills in the clinical management of emotionally
and behaviorally disturbed children.

 
  

43

Psychiatrist’s progress note about a child with a reported FSIQ = 53,
previously noted above as Item 87 in the List of 100 incidents in Table 1.
In this instance, the gratuitous remarks about the patient’s lack of “insight”
and “judgment” are made in the context of a hospital unit where aggressive
behaviors are a daily occurrence; in fact, the same progress note reported
that this child “was attacked by 3 peers in retaliation” a day earlier.
As far as this psychiatrist’s progress note is concerned, however, the
operative problem is the failure of a mentally retarded child to exercise good
judgment, not the failure of hospital officials, clinicians and staff to ensure a
safe environment.

41

 Xxxxxxxx
NOTE: UIC reviewers routinely noted the amount of time that
UHS Hartgrove psychiatrists spent with patients on the units,
as indicated in the sample observations below. 44

Table 3.
Observations by UIC
team of amount of time
some UHS Hartgrove
psychiatrists spend
talking with patients.

•

12.30.10
Dr. XXXXX sees patient (non-ward) for intake evaluation
from 9:13 AM to 9:18 AM [-5 minutes]; observed dictating
evaluation on nursing station telephone from 9:20 AM to
9:23 AM [< 4 minutes].

•

12.30.10
Dr. XXXXX gets non-ward at 9::26 AM and is finished at
9:28 AM [< 3 minutes].

•

12.30.10
Dr. XXXXX gets non-ward at 9:30 AM (patient got into a
fight last night) and is finished by 9:33 AM [< 4 minutes].

•

12.30.10
Dr. XXXXX takes next patient (non-ward) at 9:33 AM,
says he’s covering for Dr. XXXXXXXX, and is finished
at 9:36 AM [< 4 minutes].

•

12.30.10
Dr. XXXXX takes next patient (non-ward) at 9:37 AM,
says he’s covering for Dr. XXXXXXXX, and is finished
at 9:40 AM [< 3 minutes].

•

12.30.10
Dr. XXXXX gets MS (DCFS ward) at 9:40 AM and is
finished at 9:43 AM [< 4 minutes].

•

12.30.10
Dr. XXXXX gets another patient (non-ward) at 9:45 AM
and is finished by 9:48 AM to go to a staffing [< 4 minutes].

44

UIC’s sources among hospital staff reviewed this time sample data and
agreed that it was an accurate portrayal of the amount of time psychiatrists
typically spend engaging with patients on the units; several sources used
the term “assembly line” to describe the view from the nursing station as
psychiatrists briefly talked with patients over the counter or in the hallway
before completing their progress notes.
In fairness, certain psychiatrists were known to spend 10-15 minutes or
more daily with their patients, and they were readily identified (by the UIC
reviewers as well as by hospital sources) as exceptions to this fast-track
process.
UIC reviewers also compared these observations with progress notes by
psychiatrists on individual patients, as discussed in the following section of
the current report.
 
  

42

 Xxxxxxxxxxxx XXXXXXXX

 
  

•

12.30.10 9:48 am:
Dr. XXXXXXXXX gets patient (non-ward) at 9:48 AM and
is finished by 9:50 AM [< 3 minutes].

•

12.20.10
Dr. XXXXXXX gets patient (non-ward) at 10:20 AM and
is finished by 10:26 AM [< 7 minutes].

•

03.01.11
Dr. XXXXXXXXXX stands talking to patient (non-ward)
at end of hallway from 1:05 to 1:13 PM [-9 minutes].

•

03.08.11
Interview with DCFS ward” “Dr. XXXXXXXX is my doctor;
I see him 2-3 times a week for about 5 minutes.”

•

03.22.11
Interview with DCFS ward: “I see Dr. XXXXXXXXXX every
day for a little while. “

•

05.03.11
Dr. XXXXXXXXX gets female pt (non-ward) goes to end
of hall by window at 3:44 pm, sits on floor for session and
is walking back to nursing station at 3:46 PM [< 3
minutes].

•

05.03.11
Dr. XXXXXXXXXX gets male pt (non-ward) from dayroom
at 3:47 PM and is finished by 3:49 PM [< 3 minutes].

•

05.03.11
Dr XXXXXXX gets different male patient (non-ward) from
dayroom, walks down hall talking with him from 3:50 PM
to 3:52 PM [< 3 minutes].

•

05.19.11
Interview with DCFS ward: “Dr. XXXXXX sees me every
day for 1-2 minutes and argues with me about pills.”

comments on DOCS

43

 xxxxxxx XXXXXX

Selected case reviews of DCFS wards.

Selected case reviews
of DCFS wards treated
at UHS Hartgrove during
the past 12 months.

This section briefly details quality of care concerns with selected
individual cases that were identified by the UIC team during the
course of examining medical charts, treatment/discharge plans
and other records of DCFS wards admitted to UHS Hartgrove
Hospital during the period from January 2008 through June 2010.

Xxx Xxxxxxxxxxx
XXXXXXXX

Case # 1: AH
AH, a 15-year-old boy admitted to UHS Hartgrove on 4/27/11,
had eight psychiatric hospitalizations in 2010 and six admissions
as of this report in 2011.

 
  

Clinical/Behavioral Management Issues. While this patient
presents challenging behavioral management issues for clinical
staff in any setting, whether residential or hospital, his frequent
hospital re-admits – sometimes within hours or a few days of
discharge – suggest that neither hospital or residential clinical
staff (nor, for that matter, DCFS) have developed effective plans
to address his treatment stabilization needs.
•

On his only 2010 UHS Hartgrove hospitalization, where he
was admitted on 3/29 from the Costigan Residential Center,
it should be noted that he was discharged from Streamwood
Hospital (SBHC) only three days earlier.45
AH was discharged from UHS Hartgrove 17 days later (4/15),
then apparently re-hospitalized that same afternoon at SBHC.
According to a psychosocial assessment at SBHC, AH stated
“I got transferred for cutting”; the SBHC psychiatric admission
note indicated that “at Hartgrove pt was disrespectful to staff,
assaultive and aggressive to property.”

•

AH was re-admitted to Hartgrove from the Costigan Center
on 4/27/11, and on 5/6/11 he alleged that his roommate on
the adolescent boys unit had been “touching” him for several
days. When asked why he hadn’t said anything to staff earlier,
AH replied that he was scared because his roommate was
much larger than him. AH was then moved to a single (or
“blocked”) room.46

45

Both the Costigan Residential Center and Streamwood Hospital (SBHC)
were acquired by Universal Health Services from Psychiatric Solutions Inc.
(PSI) as part of a corporate takeover, effective November 15, 2010.
46

Of interest, AH has been in a special SACY program for several years
while at the Costigan Center, although this SACY placement was curiously
described as a “group home” in a psychologist’s note following re-admission
to UHS Hartgrove on 4/27/11; the note appeared to minimize any potential
risk of sexually problematic behaviors, which may explain why AH was not
initially placed in a “blocked” room at Hartgrove.  
  

44

 However, when AH was visited by his regular therapist from
the Costigan Center’s SACY program, he reported to her that
“two night ago he woke up and his roommate was touching his
penis under his clothing; reportedly the roommate then got on
top of him and was moving up and down…over their clothing.”

 
  

According to the Costigan therapist, AH stated “the following
night his roommate got on top of him, pulled down his pants
and put his penis into his buttocks…[He] stated he tried calling
for help but no one came.”
The Costigan therapist’s chart note added that AH “expressed
feeling very unsafe at Hartgrove and asked this writer to try to
get him moved.” 47
•

AH was discharged the next day, 5/27/11 – after being sent to
the emergency room at Norwegian Hospital for examination –
then re-hospitalized later that day at Streamwood Hospital for
about five days; AH was again re-hospitalized at Streamwood
about a week later (5/19/11), where he was then interviewed
by UIC reviewers on 6/3/11 and 6/7/11.48

47

Also of interest, the note written in the late afternoon of 5/6/11 by the
Costigan Center therapist, who was apparently consulting with Hartgrove
staff, made the following comments:
• “Writer met with therapist and 2 staff from Hartgrove unit.
Writer asked if hotline had been called & therapist reported
that it had not because [hospital staff] were still investigating.”
“Writer informed them of the additional info the pt reported,
that the roommate had anally penetrated him, and the staff
questioned why his story changed. Writer explained that she
worked with pt for >1 yr and he may not have same level of
trust with the hospital staff. Also, she is his sexuality therapist
[and] he seemed extremely ashamed when he reported what
occurred.”
“Writer also asked if the police were called and [Hartgrove]
therapist said she didn’t know because they needed to finish
their investigation.”
UHS Hartgrove records indicate that a DCFS hotline call was subsequently
made at 4:35 PM on 5/6/11.
 
  
48
UIC reviewers found that AH had been ingesting foreign objects at SBHC
(i.e. AAA batteries, screws and a small screwdriver), despite the fact that he
was placed on a 1:1 staff observation; two days after AH was interviewed by
the UIC reviewers, a psychiatrist’s order raised this to a 2:1 observation.

45

 •

 
  

With regard to managing this patient’s very provocative and
even dangerous behaviors, SBHC and the Costigan Center
appear to have been just as ineffectual as UHS Hartgrove –
and DCFS must acknowledge its share of responsibility for
failing to identify the pattern of woefully inadequate treatment
and aftercare planning services this child has received since
becoming a ward.
Moreover, the settings in which those services were provided
have also posed serious risks of harm, as evidenced by the
spiral fracture AH received during an inappropriate restraint
hold at the Costigan Center on 12/31/10. AH reported during
an interview with UIC reviewers that “when XXXXXXXX and
XXXXXXX [names redacted] heard my arm snap they let go”
[see Illustrations 1 & 2, below]. 49 50

Xxxxxxxxxxx

Illustration 1.
Surgical scar following
operation to repair the
spiral fracture injury to
AH’s right arm.

 
  

Photo taken by UIC reviewers during first interview with AH at SBHC
on 6/3/11.

49

The 2010 UIC report on Streamwood Hospital also found evidence of an
extraordinarily high rate of patient restraint injuries at the Costigan Center –
including fractured arms – a rate as much as three to four times higher than
other residential facilities serving high-end DCFS wards.

 
  

50

As discussed earlier, an inappropriate restraint hold by UHS Hartgrove
staff caused a similar fracture to the arm of a non-ward on the adolescent
boys unit on 5/5/11, according to confidential UIC sources at the hospital,
and DCFS confirmed to the UIC team that a hotline call was made about
this incident by hospital officials. The circumstances surrounding this injury
were the focus of intense scrutiny in the 2011 CMS report on Hartgrove,
although the CMS surveyors were unaware at that time of the questionable
restraint training issues identified in the current UIC report.

46

 Xxxxxxxxxxxxx

Illustration 2.
X-ray film showing
spiral fracture injury
to AH’s right arm on
12/31/10.

 
  

Xxxxxxxxx XXXXXXXX

Summary.

 
  

Despite the complex clinical and behavioral management issues
that AH presented, the medical records detailing his treatment at
UHS Hartgrove indicate the same pattern of quality deficiencies
that were noted throughout other patient records at the hospital
by both CMS and UIC:
•

AH’s treatment plan was not individualized to address his
identified clinical issues, beyond a simple check-listing of
behavioral problems, nor were there any indications about the
specific treatment interventions that clinical staff would utilize
to help this patient achieve his therapeutic goals; in fact, other
than the standard boiler-plated checklist, the plan was marked
by an absence of well-defined and achievable goals.
47

 Xxxxxxxxx XXXXXXXX
Specifically, the itemized problem list in AH’s treatment plan
consisted of the following:
#1 Aggression (Pt was threatening staff at group home)
#2 Asthma
#3 Suicidal (Pt tried to swallow necklace to choke self)
#4 Self Injurious (Superficial marks on arm made w/ pencil)
#5 Hypothyroid

 
  

However, the treatment plan makes no mention of AH’s known
sexual acting-out behaviors, even though he was admitted
from a SACY program at the Costigan Center.
Similarly, there was no indication that AH has an FSIQ = 75,
a borderline cognitive level that most clinicians would likely
take into account when developing therapeutic interventions
for unit staff to employ when working with a child who might
display episodes of anger, low frustration tolerance, mood
swings and poor judgment.
AH’s treatment plan is silent on the issue of what to do about
his self-injurious behaviors, especially his history of ingesting
objects (batteries, screws, broken glass, etc.) – although one
chart note on 5/3/11 confirmed that the patient “continues to
put objects in mouth.”
Other than itemizing aggression as AH’s # 1 problem – and
therefore presumably the main focus of treatment – there is
no specific plan for addressing this issue – although there are
numerous progress notes throughout the chart recording his
outbursts of aggressiveness, impulsivity, irritability and fighting
with peers.
•

Progress notes by psychiatrists and nursing staff over the
course of AH’s hospitalization are equally descriptive of his
negative behaviors on the unit but make little or no effort to
articulate a coherent and individualized treatment strategy,
and there were few indications that clinicians understood the
requirement to chart the patient’s response to the therapeutic
interventions as well as progress toward MTP goals.
Unfortunately, even when simply describing AH’s behaviors
nursing staff as well as psychiatrists exhibited a tendency
toward negative attributions, sometimes in a non-therapeutic
tone of frustration about the patient:
-

“Pt continues to present as manipulative & apathetic
to treatment…Instructed that any further manipulative
behavior would be consequence with essays.”
48

 Xxxxxxxxx XXXXXXXX

 
  

-

“Pt refused to deescalate & process w/ staff.”

-

“Pt unable to de-escalate & needed escort to QR for
further processing.”

-

“Pt has demonstrated that he is easily agitated by his
peers. Pt has had trouble controlling his anger when
staff have tried to intervene.”

-

“Pt has been highly oppositional and defiant.”

Essentially nowhere in the nursing progress notes for AH is
there much detectable effort that staff understood the need
to chart about the patient’s progress toward treatment goals
– even with regard to the boiler-plated/check-listed goals –
suggesting that charting is viewed as a paperwork exercise.
Finally, since the nature and content of psychiatric progress
notes are clearly spelled out in federal healthcare regulations,
the UIC team was struck very early in the review process by
the consistent departure from expectable standards, seen
throughout the UHS Hartgrove charts, for all of the dozens
of DCFS wards whose cases were examined.
AH’s case was no exception to this general finding, where
the attending psychiatrist repeats variations of the same
daily progress note comments throughout the chart:
-

“Agitated, fighting, mood swings, Impulsive.” [Illegible
written comments.]

-

“Agitated, aggressive, impulsive, easily provoked.
Oppositional, [illegible comments]. No med changes.
Mood stated “OK”. Mood restricted.”

-

“Pt impulsive, irritable, distracted, requiring frequent
PRNs secondary to fights w/ peers/staff. Says blames
“med”. Denies feeling depressed, no AH/SI. Reviewed
Lab. Recently changed meds. Mood “fine”. Labile,
circumstantial, loose.”

-

“Pt still impulsive, irritable, manipulative. No SI. No med
S/E. Easily upset. No med changes. Circumstantial,
labile, loose, pressured speech.”

In none of the eight meetings with AH does the psychiatrist
note the amount of time spent with the patient, nor is there
any mention of AH’s suicidal feelings; in fact, the only chart
note mention of depression is on 5/2, when the psychiatric
progress note simply indicated that the “pt denies feeling
depressed, no AH/SI.”
49

 Xxxxxxxxx XXXXXXXX
•

 
  

Medication issues identified in AH’s chart.
While AH’s chart notes reflected that he remained irritable,
easily agitated and impulsive, in addition to being verbally
and physically aggressive toward peers and staff during his
hospitalization, the record appears to indicate a good deal
of miscommunication and confusion about psychotropic
medication usage with this patient.
In fact, AH highlights a number of the concerns the UIC team
had about medication management practices at Hartgrove:
-

At the time of admission from the Costigan Residential
Center on 4/27/11, AH was on lithium carbonate, ziprasidone (Geodon), fluoxetine (Prozac), and guanfacine
(Tenex), but the attending psychiatrist at Hartgrove,
XXXXXXXXX, wrote an order to discontinue all
medications.51

-

Dr. XXXXXXXX planned to switch AH to divalproex
sodium (Depakote ER), and the Hartgrove unit nursing
staff sent a consent request for the Depakote ER to
DCFS on 4/29/11 a Friday). UIC’s Clinical Services in
Psychopharmacology unit recommended approval for
administration of Depakote ER on 5/2/11 (the following
Monday), and DCFS consented to the administration
of the Depakote ER on 5/2/11.

-

On 5/3/11 Dr. XXXXxXXX decided to restart Geodon,
Prozac, Tenex, and Lithium. While Hartgrove completed
two separate consent request forms, there is no evidence
that nursing staff ever sent the FAX sheets to DCFS’
consent unit; specifically, there was no FAX confirmation
sheet in the chart and neither DCFS or the UIC Clinical
Services in Psychopharmacology unit received a FAX
consent form about AH’s medication. 52

-

According to the Hartgrove Medication Administration
Record, however, only one dose of Depakote ER was
administered during AH’s hospital stay (on 5/5/11). It is
unclear why there was nearly a 3-day delay in starting
this medication.

51

 
  

Abrupt discontinuation of psychotropic medications is discouraged due to
the risk of sudden withdrawal symptoms (e.g., hypertension upon discontinuation of alpha-agonists) or rebound worsening of behavioral/psychiatric
symptoms (e.g., increasing symptoms of depression upon sudden discontinuation of an antidepressant). 
  
52

For security purposes, FAX machines at UIC and DCFS are programmed
so that UIC receives a pdf copy when DCFS receives a FAX consent form,
providing a redundant system that facilitates the timely completion of the
consent request and decreases the likelihood that a FAX consent request
sent by a facility will be lost.  
  

50

 -

Since UHS Hartgrove never received any DCFS consents for
these medications they were never started. Consequently,
during his 10-day hospital stay, AH received only one scheduled dose of a psychotropic medication. What is therefore
remarkable is that Dr. XXXXXXXXX wrote four progress notes
for AH (4/28, 5/2, 5/4, and 5/5) indicating that the patient had
no side effects from the medications – despite the fact that the
patient had only received one dose of a scheduled psychotropic
medication during his hospital stay.

All of this would suggest an array of communication issues
involving psychiatric and nursing procedures in the hospital,
beginning with the need for stronger medical/administrative
oversight by UHS corporate and hospital officials; it might
also help if psychiatrists invested more time actually talking
with patients instead of charting progress notes that fail to
add value to the treatment record. 53

53

The UIC reviewers queried the clinical psychopharmacology database,
maintained for DCFS by the UIC Department of Psychiatry, with regard to
the deficiency rate for UHS Hartgrove; a deficiency means that the consent
form (1) had missing information (such as diagnosis, symptoms, weight,
medical conditions, etc.), (2) was illegible or (3) was inconsistent with the
DCFS/UIC data about the child). Such common errors slow down the
consent approval time, which averages 15.5 hours for Hartgrove during
the normal M-F work week; the statewide average is only 6-7 hours.
o

Of interest, while the average statewide deficiency rate is 65-67%
from all hospitals, RTCs or clinics seeking medication consents for
DCFS wards, the deficiency rate for UHS Hartgrove is 85.5%
(or 183 out of 214 cases in which medication consents were sought
for DCFS wards between January and July 2011).

51

 Xxxxxxxxxxx XXXX

Case # 2: WP
WP, a 16-year-old boy admitted to UHS Hartgrove on 7/21/10
for suicidal ideation and depression, later committed suicide
on 9/13/10, 25 days following his discharge from the hospital.
DCFS case records obtained by the UIC reviewers show that
WP killed himself one day after visiting the grave of his mother,
who died of cancer when he was 9-years-old.

 
  
 
  
 
  

Clinical/Behavioral Management Issues. During the course of
his 29-day hospitalization, WP’s Hartgrove records show the
following history and clinical information:

 
  
 
  

•

The 
  patient 
  is 
  currently 
   
   
   
   
   
   
   
   
   
   
   
   
  
a 
  danger 
  to 
  self 
  and 
  others 
  
…especially 
  in 
  light 
  of 
  his 
  
•
depression, 
  impulsivity, 
  
substance 
  abuse 
  and 
  
recurrent 
  thoughts 
  of 
   
   
   
   
   
   
   
   
   
   
   
   •
self-­‐harm. 
  

 
  

 
  
•

Report of psychological evaluation
conducted at UHS Hartgrove on
August 9, 2010, over a month before
this DCFS ward committed suicide.

 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  

DCFS integrated assessment pre-admission indicated risk
factors included: suicidal statements, alcohol intoxication
and cannabis usage.
Admission diagnoses at Hartgrove listed: “Mood Disorder
secondary to substance abuse”; Adjustment Disorder; and
“family issues, unresolved grief with mother’s passing.”
Axis I discharge diagnoses listed: Depressive Disorder NOS
and PTSD; under Axis IV, the discharge findings simply listed
“psychosocial and environmental problems” and “problems
with primary support.”
Of concern, the initial psychiatric note as well as a number of
psychiatric progress notes in WP’s chart appear to be written
not by the attending psychiatrist, [name redacted], but by a
fourth-year medical student who was apparently performing
a clinical rotation at the hospital.
In fact, most of the psychiatric progress notes with narrative
comments suggesting actual engagement with this patient
were written by the medical student, sometimes co-signed
by the attending psychiatrist; at other times, progress notes,
either by the attending psychiatrist or by a second psychiatrist
[name redacted], were perfunctory in nature, provided little
evidence of contact with the patient, and were irrelevant to
any measurable goals of the treatment plan.

•

Although WP’s Master Treatment Plan at Hartgrove identified
alcohol/substance abuse as problems to be addressed during
hospitalization, there is no evidence that he received effective
treatment for this issue other than attending group sessions
run by staff on the adolescent unit; the MTP noted that this
problem was subsequently “closed” on 8/9/10.54

54

WP’s chart indicated little or no effective psychotherapeutic treatment of
any kind – and certainly nothing related to treating the “substance abuse…
and unresolved grief with [mother’s passing” that was accurately identified
as part of the diagnostic assessment at admission.

52

  
  
 
  

•

As with the clinical documentation for other DCFS wards
reviewed by the UIC team, WP’s treatment plan reviews
appeared essentially generic and non-specific with regard
to establishing measurable treatment goals or specifying
just how the therapeutic services would be delivered.
Curiously, Problem # 1 on WPs Master Treatment Plan was
identified as aggressive behavior, which was not a direct
precipitant of the hospitalization; there apparently were some
minor altercations with peers on the unit following admission,
but these occurred after the MTP was written.55 56
Of special concern, the diagnostic use of the term “aggressive
behaviors” is often found on the problem lists of many youths
admitted to UHS Hartgrove – and no doubt appropriately so
in specific cases – but it can also mark a clinical boiler-plate
approach to the treatment process, especially when there are
virtually no written indicators of precisely how clinical staff will
assist patients to achieve the therapeutic goals of reducing or
eliminating such aggressive behaviors.

•

More to the point, while the clinical records suggest that WP
was being treated for a problem that had little (or marginal)
relevance to his hospitalization, there appears to have been
only secondary attention paid to the clinical issue that ought
to have been the primary focus of treatment: the presence of
Major Depression and an extreme risk for suicidal behavior.

•

What therefore makes the case of WP so tragic is not simply
that such diagnostic issues were minimized in the treatment
and discharge planning but that available clinical data about
potential his risk factors was apparently disregarded by the
treatment team well in advance of discharge.
o

Specifically, a psychological evaluation found WP was
“currently a danger to self and others; he is at risk for
fragmentation, especially in light of his depression,
impulsivity, substance abuse and recurrent thoughts
of self-harm and lack of support system.” 57

55

WP self-reported that he been involved in an aggressive incident about
a week prior to admission, but this was unrelated to the behaviors leading
to his hospitalization at Hartgrove on 7/21/10.
56

WP’s treatment plan review on 7/27/10, six days after admission, noted
that there were no aggressive incidents since admission and that the patient
therefore “seems to be in remission for the period of hospitalization.”  
  

 
  

57

Problem # 4 on the MTP – potential for harm toward self – was “closed”
on 8/9, the same day this psychological evaluation was completed and more
than a week before WP’s discharge to the community.

53

 o

Moreover, the psychologist who conducted the evaluation
of WP indicated an Axis I diagnosis of Major Depression
(recurrent, severe).
Additional findings for WP included an FSIQ level = 70,
falling in the Borderline Range of intellectual functioning,
complicating the development of an effective therapeutic
strategy for such a depressed but limited patient.
The UIC reviewers could find no evidence, however, that
the treatment team took this clinical data into account
when reviewing the MTP’s goals (including making any
changes in clinical guidelines for unit staff assigned to
work with this patient);58 nor was there any indication
that the treatment team modified WP’s discharge plans
in light of the report’s findings and recommendations.59

o

Psychological testing revealed WP as “an extremely sad
adolescent who deeply grieves the loss of his mother and
the separation from the man who served as a stepfather
to him”:
“He is preoccupied with the loss of both of these
significant individuals and feels hopeless and alone
without them. When issues of abandonment and
isolation become too intense, he harbors suicidal
ideation, and it was unclear whether he had a plan
because he became guarded around this issue.
“Still, his tendency to self-medicate his depression
and anxiety via marijuana and alcohol… increase
the likelihood he may act on such an impulse.”
The psychological evaluation concluded:
“While there were no signs of a formal thought
disorder, when WP becomes overloaded with
emotions, he is prone to experience transient
ruptures in his reality testing which lead him to
exercise poor judgment and behave impulsively.

58

Among the chart notes by staff, for example, were comments such as:
“patient refused to use his coping skills” and “patient was encouraged by
staff to focus on self-improvement.”
59

Specifically, the psychologist’s report indicated that WP needed “a safe
and structured environment with adequate limit setting and attention.”
Instead, WP’s treatment plan review on 8/9 showed that the discharge plan
was for him to go to a “temporary foster home” setting.
Of concern, since this treatment review note was written on 8/9, the same
day WP’s psychological testing was completed and available to the team,
it would appear that either: (a) no one on the treatment team read the report
or (b) the findings were simply disregarded.

54

 Summary.
Let us be clear: the UIC reviewers have no interest in offering
post hoc ergo propter hoc speculation regarding the suicide of
this child. Despite what in retrospect appears to be a prescient
assessment of the danger WP posed to himself, no one could
have “predicted” this tragic event, notwithstanding the clinical
insights that are contained in the psychological evaluation.
That said, the remarkable critical failures in this case would
arguably be cause enough for alarm even if the findings of the
current UIC report had been submitted on the day before WP
was scheduled for discharge from the hospital.
DCFS and UHS Hartgrove both failed to ensure that this child
received the level of care and treatment he needed to address
his identified mental illness and behavioral disturbance:
•

DCFS failed to provide an adequately structured environment
that could offer post-discharge stability for a vulnerable ward;
further, the Department will need to honestly examine its role
in this and other cases where an inefficient system appeared
to Ignore substandard quality of care provided to its wards.

•

UHS Hartgrove failed woefully at many levels in this case,
most egregiously by not developing effective treatment and
discharge plans for a patient whose vulnerabilities had been
clearly identified, and eloquently documented, by at least one
very competent clinician at this hospital.

The fact that UHS corporate officials (in 2009), as well as CMS
and UIC (in 2011), identified inadequate treatment and discharge
planning as critical problems at Hartgrove Hospital should give
DCFS reason to question the care all of the Department’s wards
received during that period, especially since it is evident that the
substandard care provide to WP was not a single-case failure.
•

Medication issues identified in WP’s chart.
As with the other three cases of DCFS wards, similar issues
were identified regarding miscommunication over medication
consent requests:
o

On 7/24/10 a medication request was faxed by nursing
staff at UHS Hartgrove to the UIC/DCFS consent unit
for Lexapro 10 mg po q AM up to 30 mg/day; and there
is a fax confirmation sheet for Lexapro in WP’s chart.

o

Dr. Naylor consulted on this request that same day,
at 4:30 PM, commenting that: (1) the symptoms listed
on the request form sent by Hartgrove did not support
a diagnosis of depression or the use of anti-depressant
medication; and (2) the range of Lexapro 30 mg was not
approved as the maximum range for Lexapro is 20 mg.
55

 Per the UIC/DCFS consent unit, “Suicidal statements
and drug and ETOH abuse” were the symptoms initially
reported on the form. “Sad r/t biomom’s death and
depression” were not added until 7/26/10 at 3:44 PM,
two days after the initial request was submitted.
On 7/26/10 a request for one medication was received
at the UIC/DCFS consent unit for Lexapro. Dr. Naylor
provided clinical consultation on 7/26/10 and approved
Lexapro 10 mg.

56

 X xXXxxxxxxxx XXXXXX

Case # 3: AC
AC is a 16-year-old female ward with severe sickle cell anemia
who has experienced at least a dozen psychiatric hospitalizations
since 2008, including eight at UHS Hartgrove.60
Pain is the principal symptom of sickle cell disease, and AC’s
records indicate that her frequent and ongoing medical crises
resulted in 11 medical hospitalizations between January and
early March 2011, one of which was completed the same day
she was admitted to UHS Hartgrove (3/10/11).

Pt is unable to utilize
any coping skills…
is med-seeking, needy
…and demanding.

During the initial psychiatric assessment at Hartgrove in March,
AC told the psychiatrist that her disease was “tearing up my life,”
poignant testimony that is underscored by the medical history
and frequent crises described below.61

 
  

 
  

Progress notes by psychiatrist
in AC’s chart at UHS Hartgrove.

Clinical/Behavioral Management Issues. In light of this child’s
demonstrably overwhelming experience of pain from her disease,
the UIC reviewers were especially alarmed to discover how the
UHS Hartgrove staff and clinicians evaluated and responded to
her symptom-related behaviors on the unit.
•

“Pt is unable to utilize any coping skills, became
tearful & demanding. Pt is med-seeking & needy.”

AC responds positively
when she feels adults
take the time to listen
to her and work with
her to address her
concerns.
 
  

In particular, the treatment plan review for 4/12/11, signed by
the attending psychiatrist and unit charge nurse, noted that:

•

Similarly, progress notes in AC’s chart throughout the course
of her final UHS Hartgrove hospitalization reveal that such
insensitive and ill-informed views of this patient’s difficulties
were not uncommon:
03.24.11
“Pt continues to stand at nursing station, requesting meds for
pain in legs. Refused to move when asked by staff & claimed
she ‘will go off’ if she doesn’t get ‘anything.’”

 
  

Comments about AC in the
discharge summary from the
CATU program, following her
transfer from UHS Hartgrove
to the UIC Medical Center.

03.26.11
“Pt standing at nursing station, requests for medication after
already being treated. Pt crying & yelling. [Patient was then]
escorted to QR, where she said she didn’t want to live
anymore; denied having a plan.”

60

For the purpose of the current review, the UIC team was only able to
examine clinical records for the last of the eight UHS Hartgrove admissions.
61

According to the initial psychiatric assessment at Hartgrove, the severity
of her sickle-cell disease increased over the past year, requiring medical
hospitalization two or three times a month.

57

 Xxxxxxxxxxxx XXXXXXXX
04.11.11
“Pt becoming highly agitated, punching walls & pictures
when this writer told her that [medical consultant] was
paged & we were awaiting call back to see if pt could
receive more pain medication.”
“Pt was offered hot packs at that time while awaiting
MD callback, but responded by saying ‘Fuck you all,
you ain’t trying to do shit for me.’”

Pt stated she doesn’t
care about getting
better. Admits to
giving-up attitude
& not putting any
effort to applying
any coping skills…
 
  

“Psychiatrist [name redacted] called at 10:30 AM and
informed of patient’s increasing pain, agitation and
aggression, and that pt was escorted to QR, where
staff continued to attempt to de-escalate pt.”
“Pt again noted to curse at staff…[Attending psychiatrist]
arrived on unit and attempted to talk with pt while [she
was] being monitored in quiet room.”62
Progress note at 10 PM indicated: “Pt impulsive and
demanding. Became quickly agitated when things
didn’t happen during her timeline. Went to hospital
to address medical needs.”63

 
  

04.06.11 - Note by attending psychiatrist:
“Pt continues agitated, angry in session: ‘I don’t care
anymore. I don’t want to get better. I’m sick of this
place. Nothing works for me.’”
“Pt stated she doesn’t care about getting better.
Admits to giving-up attitude & not putting any effort
to applying any coping skills…, stated everything
irritates her & she just needs stronger medicine to
calm her down.”
“Discussed with patient that meds are not the answer to
control her behaviors. She needs to work on addressing
the problem & not just seek to be medicated. Verbalized
minimal feedback in the session, very guarded, not
forthcoming with information. Continue Tx plan.”
62

UIC note: AC received 1x dose of Demerol 25 mg IM at 11 AM, which
reportedly reduced her pain. She was able to process with staff about her
agitation at about 11:30 AM. Chart notes indicated “pt now appears more
comfortable & no longer noted to be cursing at staff,” although the note
concluded that AC was continuing to “blame others… [and] taking little
responsibility for her actions.”

 
  

63

Note the 6.5-hour period between the initial phone call to AC’s psychiatrist
(10:30 AM) and the time the ambulance arrived to take her to the medical
hospital [5 PM], during which staff apparently perceived this child as being
“quickly agitated when things didn’t happen during her timeline.”

58

 Xxxxxxxxxxxx XXXXXXXX
05.04.11
“Pt upset about being in pain and has regularly been
crying & yelling at staff. Staff called MD about changing
pain meds… but pt remained agitated, ripped a picture
off the wall in protest. Staff took her to QR & processed
with her & she was able to calm after Thorazine 100 mg
IM…, but still impulsive & demanding.”

 
  

05.05.11 – Note by attending psychiatrist:
“Pt’s case discussed in multidisciplinary team staffing…
“Very difficult to assess if patient is med-seeking
given the fact there is no objective way to assess
[her] level of pain.”
[Patient] “given Oxycontin ER 15 mg. po at 2:30 PM…,
still ranked pain as 10/10. 3 PM pt stated: ‘I’m still in pain,
med is not doing anything.’ Encouraged to give med time
to work; pt sat back in her chair and moaned.” 64 65 66

64

Hartgrove records indicated AC was never taken to see a hematologist,
but on 5/6/11 – 57 days into her hospitalization at Hartgrove – she is finally
taken to [name redacted], a pain specialist at Weiss Hospital. It should be
noted that during this 57-day period, AC was taken to the ER four times.
While there is no record of the Weiss consultation in AC’s Hartgrove chart,
the specialist apparently increases pain medication by tripling the dosage
level of her Oxycontin, going from 10 mg twice daily to 30 mg (total = 60 mg
daily); however, this increase led to the patient vomiting, so ultimately the
total daily dosage was increased by 15 mg twice daily (total 30 = mg daily).
•

Although the pain specialist preferred that Oxymorphone be used, it was
unavailable at Hartgrove; Oxycontin was given until Oxymorphone could be
ordered. The pain specialist also apparently discontinued the use of Norco
10/325 prn for “breakthrough pain” and ordered Percocet 10/325 1 tid prn.
[Breakthrough pain is pain that occurs in between the regularly scheduled
Oxycontin every 12 hours; Compazine was also being given IM STAT for
any nausea and/or vomiting that occurred as a side effect of Oxycontin.]

Specific dosage levels aside, the issue here is that the pain specialist
appears to have concluded that the regimen of pain medication AC had
been receiving was significantly lower than her medical condition required.
65

Of interest, AC’s treatment plan for management of her sickle cell pain
indicated that nursing staff would educate her once weekly about ways to
relax (i.e., deep breathing, repositioning, back rub, etc.); according to the
charted progress notes, however, this occurred only once, on 4/19/11.
66

See: The Management of Sickle Cell Disease. National Institutes of
Health; NIH Publication No. 02-2117, Fourth Edition, Revised June 2002.
With regard to the treatment of SCD, the NIH publication indicates that:
“Ideally, parenteral meperidine [Demerol] should no longer be used…as
first-line treatment of acute pain. It has a long half-life and is a cerebral
irritant, so accumulation can cause effects ranging from dysphoria
and irritable mood to clonus and seizures. [Emphasis added.]

59

 Xxxxxxxxxxxx XXXXXXXX
05.10.11 - Note by attending psychiatrist:
“It’s obvious pt’s most disruptive behavior related
to her physical symptoms. Whenever she is in pain
or not feeling good, pt starts acting-out.”
“She has low threshold regarding her ability to handle
physical distress, continues to show poor motivation
to learn appropriate coping skills.”

 
  

Transfer of AC to CATU Unit at UIC Medical Center. AC was
transferred to the CATU unit at the UIC Medical Center on 5/11/11
– the day after the above note by the Hartgrove psychiatrist was
written – where she was treated both on the inpatient psychiatry
unit and the pediatric medical unit; she was discharged 48 days
later, on 6/27/11, to a residential program in the Chicago Area
and is reportedly now doing well in that setting.
Given that AC had seven prior admissions to UHS Hartgrove,
the woeful failure to effectively address this child’s identified
clinical and medical problems is very troubling – all the more so
because the CATU staff saw essentially none of the seemingly
out-of-control behaviors AC displayed during her hospitalization
at UHS Hartgrove.
On the contrary, the CATU clinicians indicated that AC actually:
•

“Did a nice job of coping on CATU… and demonstrated good self
regulation in groups during her hospitalization.”

•

“Attempted and often mastered each activity, asking for help when
needed and managing frustration with little assistance [from staff].”

•

“Self-identified

working on her anger as a treatment goal.”

CATU clinicians also noted that AC reported a history of ADHD
as well as difficulties concentrating on certain tasks, requiring
that staff offer strategies for increasing her attention.
Of special interest, CATU staff noted that “AC was able to identify
certain triggers for her anger, including ‘people touching me,
ignoring me and not listening to me.’”
UHS Hartgrove clinicians might well ask if this is the same child
who was dismissed in their progress notes as: “unable to utilize
any coping skills…; med-seeking & needy…; quickly agitated
when things don’t happen during her timeline…; impulsive and
demanding…; [and] not caring about getting better.” 67
67

Table 4, below, contains a partially redacted discharge summary and
aftercare recommendations provided by the CATU treatment team, based
on the comprehensive assessment of AC during her UIC hospitalization –
a clinical portrait that offers a stark contrast to the boiler-plated treatment
and discharge planning documents found in the UHS Hartgrove charts.

60

 xxxxxx XXXXXXXX

Summary.
The striking difference between AC’s positive outcome at the
CATU program versus the adverse events of her protracted
episodes of pain and subjective levels of distress while at UHS
Hartgrove – coupled with the insensitive and counter-therapeutic
remarks by which some UHS Hartgrove clinicians dismissed her
“med-seeking and needy demands” – suggests an iatrogenic
effect that derailed any possibility of effective treatment.68

 
  

Inasmuch as competent and effective treatment services were
withheld from this child over the course of a dozen psychiatric
hospitalizations since 2008, some of which now appear to have
been detrimental to her psychological and medical well-being,
it is evident that this DCFS ward repeatedly suffered harm as a
result of such worthless interventions. 69 70
•

Medication issues identified in AC’s chart.
Finally, a psychiatric progress note was found in AC’s chart,
dated 3/17/11 and written by a third-year medical student,
saying: “Pt seems upset about her inability to control her
mood & not being able to get consent for meds from DCFS.”
It is unknown whether AC was actually led to believe that
DCFS had been slow to approve her medications, but the
UIC reviewers were troubled by the implications of this note
and queried the clinical psychopharmacology database to
determine the facts outlined below:

 
  
o

On 3/15/11 the psychiatrist ordered Depakote but an
incomplete medication request was sent to the UIC/DCFS
consent unit on 3/16/11; an updated request was sent
and approved by the UIC/DCFS consent unit on 3/17/11.

68

AC’s discharge plan from the CATU program, which details her response
to treatment following transfer to UIC, is attached below as Table 4.

 
  

69

Going forward, DCFS should take immediate steps to ensure that AC’s
medical care for her sickle cell disease is provided in clinic settings and/or
medical hospitals that are already familiar with her medical treatment needs,
such as La Rabida Hospital.
With regard to psychiatric services, for reasons that should be abundantly
clear, DCFS should also take steps to ensure that it does not authorize any
further admissions of this child to UHS Hartgrove Hospital.
70

 
  During AC’s admission to CATU she had two medical transfers to the UIC
pediatric medical unit for sickle cell pain crises (from 5/12/11 to 5/2311 and
6/3/11 to 6/14/11). During AC’s initial stay on the pediatric unit, it took ten
days before the administration of IV narcotics alleviated her pain, and her
doctors at La Rabida Hospital noted this was a typical pattern for AC.

61

 o

TAC’s attending psychiatrist ordered Risperidone and
Prozac on 4/1/11. UIC/DCFS consent unit received the
request on 4/2/11 but noted: (1) form listed inadequate
symptoms for Risperdal; (2) the current medications
were reported incorrectly; and (3) the consent unit also
needed to know if the psychiatrist planned to begin both
medications at once or one at a time.
The consent unit reports making two telephone calls to
Hartgrove on 4/4/11 to obtain the missing data, and the
request was then completed on 4/4/11 at 4:58 PM.

In sum, whatever delay may have occurred in this case was
due to the very high deficiency rate by UHS Hartgrove staff in
submitting accurate consent forms to DCFS. [See discussion
of this issue in Case # 1, above.] 
  
x

62

 Xxxxxxxxxxxxxx

Table 4.
Discharge planning efforts
for AC during her treatment
on the CATU inpatient unit
at the UIC Medical Center.

 
  
 
  
AC desires attention
from and connections
with adults… but she
can also be sensitive
and sometimes interprets
people’s actions to mean
they don’t like her,
aren’t listening to her,
don’t enjoy interacting
with her, or don’t want
to help her…

UNIVERSITY OF ILLINOIS AT CHICAGO
Comprehensive Assessment & Response Training System
Discharge Treatment Recommendations
Name: AC
DOB: 8/6/1994
DCFS ID #: XXXXXXXXX
Admission: 5/11/2011
Discharge 6/27/2011
Attending Psychiatrist: Elizabeth Charney, M.D.
TYPE OF PLACEMENT:
A CAYIT was held on 3/9/11, which recommended residential
placement. AC was initially matched with XXXXXXXX, XXXXXXXX
and XXXXXXX. While at CATU, AC was recommended for placement
at Jewish Children and Family Services XXXXXXXXXXX Group
Home due to it being in the Chicago area, which allows AC to
maintain routine contact with her family as well as receive ongoing
medical treatment through La Rabida Hospital. AC will transition to
the group home upon her discharge from CATU.
SAFETY/MILIEU/INTERPERSONAL/BEHAVIORAL ISSUES:
1. AC has a diagnosis of sickle cell disease, and experiences
complications with symptoms of her illness. AC often
experiences pain in her arms and legs, and she can go into
pain crises that require medical attention and
hospitalization. AC has reported increased pain when she
experiences emotional distress or when she stays in her
room and isolates rather than staying active and engaged in
a normal routine. AC has relied primarily on medication for
managing her pain, and will benefit from learning to use
other methods to alleviate pain and emotional distress
earlier in an effort to avoid reaching the point of a pain crisis.
2.

3.

AC should work with staff to continue to identify and use
methods other than medication to manage her pain and try
to prevent pain crises. Some things AC can do are making
sure she remains hydrated, massaging her arms and legs,
taking warm showers, getting regular sleep, monitoring and
adjusting for temperature changes, and using a heating pad.
•

Encourage AC to use a pain scale to keep staff
informed of the degree of pain she is experiencing, and
identify what types of interventions should be utilized at
different points on the scale.

•

It is helpful for AC to stay be involved in physical
activities that aren’t too strenuous on her body. AC
would also benefit from participating in physical therapy.

•

AC should participate in the sickle cell teen support
group through La Rabida Hospital.

AC is new to the DCFS system, and her placement at
XXXXXXXX Group Home is her first placement outside of
being in the shelter. AC is looking forward to having a stable
place to live, but will require support as she adjusts to this
placement.

63

 •

AC shared concern about being used to the types of
rules that are in place in hospitals, and looking out of
place if she does things that are required there, but not
in the group home setting. Staff members should take
time to orient AC to the unit rules and routines, and
provide opportunities for her to ask questions about
how things are different there from what she’s become
used to by being in the hospital for such a long time.

•

The therapist should encourage AC to process her
feelings related to her placement in the group
home, and being separated from her family
members.

•

It will be important for AC to have opportunities to
interact with and get to know staff and her peers
on an individual basis, and in a relaxed manner to
help her feel comfortable in this new setting.

4. AC struggles with affect regulation. AC experiences
significant anxiety and has expressed fears about
negative things happening to her or her family members.
AC also reports feeling depressed about her illness,
things that have happened to her in the past, as well as
being easily disappointed when things don’t work out the
way she wants them to.
AC doesn’t inform people when she’s experiencing
distress, and she can easily become overwhelmed.
When AC is having a difficult time managing her emotions,
it tends to result in irritability, disrespectful or demanding
interactions with adults, impatience and inflexibility,
physical aggression; her becoming tearful and hopeless,
suicidal ideation or gestures (cutting herself or trying to
overdose on medication), or experiencing an increase in
her physical pain.
•

Staff members should stress the importance of,
and encourage AC to inform them about things
that cause her to feel anxious and depressed rather
than keeping these issues to herself.
Staff should work with AC to identify ways she is
most comfortable sharing her feelings and concerns,
which may include AC journaling and sharing it with
adults, or talking to them.

•

Staff should work with AC to continue to identify
and practice using coping skills to help her relax and
self-soothe when she experiences difficult emotions.
AC has identified listening to music, playing basketball, journaling, and drinking tea as things that she
enjoys and feels can help her. AC stated she is open
to trying progressive muscle relaxation and guided
imagery (I Can Relax! cd will be provided that has
exercises for her to try).

64

 •

Staff members should help AC identify things she
can do during transition times in her room so she
doesn’t focus on things that cause her to feel
anxious or depressed.

•

Staff should work with AC to continue to add to her
list of coping and self- soothing tools she will use,
and discuss which ones have been most effective.

5. AC reported having difficulties sleeping at night and being
woken up by nightmares that include graphic images of
violence toward her and her sister. When AC has
difficulties sleeping, this has a negative impact on her
functioning during the day.
•

AC would benefit from developing a bedtime
routine that includes calming and relaxing activities
before going to sleep. This routine could include
drinking tea, stretching or completing a guided
progressive muscle relaxation exercise, putting on
scented lotion, or listening to calming music.

•

Overnight staff should monitor for signs that AC is
having difficulties sleeping, and provide support if
she wakes up during the night due to nightmares

6. AC desires having attention from and developing
connections with adults, but she can be sensitive and
sometimes interprets people’s actions to mean they don’t
like her, aren’t listening to her, don’t enjoy interacting with
her, or don’t want to help her address her needs or
requests.
AC responds positively when she feels adults take the
time to listen to her and work with her to address her
concerns.
•

Staff members should take time to interact and get
to know AC on an individual basis as this will help
her feel cared about and supported.

•

It will be helpful for staff members to clarify their
roles and make sure AC knows what to expect from
each individual in an effort to minimize the
possibility that she becomes confused or has
unrealistic expectations of people.

•

Staff should encourage AC to initiate contact and
share her feelings and concerns, or seek support
when she needs it.

7. AC reports feeling frustrated when her peers become
loud, show intense emotion, act out, or don’t respect her
physical space. AC appears uncomfortable socializing
with peers, and sometimes avoids interacting with them in
an effort to avoid dealing with these types of issues.

65

 •

Staff members should encourage AC to socialize
with her peers, and discuss ways AC can develop
these relationships if she is being isolative or says
she doesn’t feel like she fits in with her peer group.

•

Staff should support AC when she becomes upset
or frustrated with her peers, and assist her in
identifying ways she can manage her responses to
them.

•

Staff members should provide opportunities for AC
to participate in structured interactions and
activities with one or two peers to promote her
participation in social interactions and developing
positive relationships.

•

Staff members should encourage AC to reach out
for support and guidance if she feels she is having
difficulties with her peer relationships.

FAMILY ISSUES:
[This section deleted for reasons of confidentiality.]
THERAPEUTIC ISSUES:
AC experienced trauma that included witnessing domestic
violence, physical abuse by her father, and sexual abuse by the
daughter of one of her father’s paramours.
AC also has difficulties in her relationships with her mother, her
mother’s paramour, and her sister. AC struggles with managing
anxiety and depression related to her past, frustration related to
her illness, and family related stressors.
AC identifies as bisexual and has experienced negative
responses from her family members that have likely contributed
to her reports that this is something she’s ashamed of, and that
she wishes she wasn’t bisexual.
AC’s mother and sister responded negatively and have had
difficulty being supportive of AC around this issue, but have told
her they love and care for her regardless of her sexual
orientation.
1. The therapist should work with AC to identify things that
trigger her anger, anxiety and depression, and identify
ways she can appropriately cope with and express these
overwhelming emotions.
2. The therapist should assist AC in exploring how her
illness impacts her self- image, self-esteem, and level of
emotional distress, and identify ways she can develop
and maintain a more positive outlook despite her health
challenges.

66

 3. AC should be encouraged to share her perspective on
the challenges in her relationships with her family
members, discuss how she would like to see these
relationships change, and identify topics to be addressed
in family therapy sessions.
4. AC reports significant sadness related to thinking about
negative things that have happened in her past, and she
should work with the therapist to process the traumatic
events that have occurred throughout her life.
5. The therapist should encourage and support AC in
exploring her sexual identity. If AC continues to express
shame and negative feelings around this, she may
benefit from participating in a support group through The
Center on Halsted or another agency.
6. The therapist should work with AC on identifying her
strengths and interests, and find ways that they can be
built into her daily routine.
7. AC should participate in group therapy that works to
develop positive life skills, emotion regulation skills,
social skills, and learning how to develop healthy
relationships.
PSYCHIATRIC/MEDICAL:
During AC’s admission to CATU she had two medical
transfers to the pediatric unit at UIC for sickle cell pain crises.
AC received medical treatment on the pediatric unit from
5/12/11-5/2311 and 6/3/11-6/14/11. During AC’s initial stay on
the pediatric unit, it took ten days before the administration of
IV narcotics alleviated her pain, and her doctors at La Rabida
Hospital noted this was a typical pattern for AC.
AC did well when she returned to CATU until her narcotic
medication was tapered off, leading to a recurrence of pain
requiring her to be transferred to the pediatric unit the second
time. AC’s medications were adjusted during her second stay
on the pediatric unit, and these changes seem to have helped
manage her sickle cell symptoms more effectively.
Discharge Diagnosis:
Axis I: Bipolar Disorder NOS
ADHD
PTSD by history
Axis II:
Axis III: Sickle cell disease
Axis IV: Separation from family and referral to RTC, chronic
pain and medical illness,
lack of schooling, trauma history (exposure to domestic
violence, sexual and physical
abuse)
Axis V: 50
AC’s medications at discharge include:

67

 RECOMMENDATIONS:
1. AC has received care for her sickle cell anemia through
La Rabida Children’s Hospital in the sickle cell clinic
with Dr. XXXXXXXXXXXXX, and it is recommended
that she continue routine medical care with them since
they have worked with her for several years, and are
familiar with her. AC’s next appointment at La Rabida is
scheduled for 9/21/11 at 2 pm. AC can walk in anytime
between 8am-9pm at the “Treatment Room.”
2. Due to the delay in resuming treatment with her routine
provider, a follow- up visit has been arranged with UIC
on 6/30/11 at 1pm in the Outpatient Care Center, Suite
2E, located at 1801 West Taylor Street, Chicago, IL.
(xxx.xxx.xxxx)
3. AC should see the psychiatrist through the XXXXXXX
group home within one week of discharge from CATU,
and then follow up at the discretion of the psychiatrist.
4. AC participated in physical therapy during her stay at
CATU. By report, AC has very tight thigh and calf
muscles, and would benefit from ongoing physical
therapy services at a local clinic. An initial home
program was provided to AC, as well as a referral script.
AC may also benefit from yoga, massage, and other
stretching/strengthening activities.
5. Consent for a neuropsychological evaluation was
obtained, but the testing could not be completed while
AC was at CATU. Arrangements should be made for
this testing to be completed.
6. AC is due for an updated eye exam, which wasn’t able
to be completed during her stay at CATU. An eye exam
should be scheduled for AC.
7. See the Psychiatric Discharge Summary dated 6/24/11
for additional information regarding psychiatric and
medical issues.
Wellbutrin SR tablet 300mg PO, DAILY
Folic acid 1mg, TABLET, PO, DAILY
Gabapentin 400mg, CAPSULE, PO, TID at 9am, 3pm and 9pm
Hydroxyurea 1,500mg, CAPSULE, PO, QHS
Risperidone 1mg, TABLET, PO, BID at 9am and 9pm
Naproxen 250mg tablet po q 6h prn pain

EDUCATIONAL/VOCATIONAL:
AC was diagnosed with ADHD at the age of ten, and reports
feeling hyper and having trouble staying focused in school.
AC has had numerous absences from school due to medical
and psychiatric hospitalizations, as well as school suspensions for disrespect and other disruptive behaviors. AC has a
current IEP that was completed on 11/10/10 to address her
emotional disability (ED) and secondary other health
impairment (OHI).

68

 A psychological evaluation completed in 2009 noted AC’s
FSIQ to be 81, while one completed in 2005 determined her
FSIQ to be 87. AC reports feeling discouraged about behind
so far behind in school, and has anxiety about her ability to
be successful in the academic setting.
1. AC will require support and encouragement to prepare
to return to school since she was hospitalized for much
of the previous academic year, as well as consistent
absences over the last several years.
2. It will be essential for group home staff to communicate
effectively with the school regarding AC’s sickle cell
disease and related complications, as well as having
clear guidelines on how to address AC’s reports of pain.
3. AC will likely experience anxiety and trouble focusing in
the school setting, and she should be encouraged to
utilize coping skills or taking short breaks from her work
to help her be successful.
4. AC may require tutoring, or other additional support to
complete her school assignments.
5. It will benefit AC to participate in vocational
programming when appropriate to develop work skills
and enhance her self-esteem.
LEISURE/COMMUNITY INVOLVEMENT:
1. Staff members should provide opportunities for AC to
engage in physical activities she enjoys such as playing
basketball or swimming.
2. AC reports looking forward to having the opportunity to
participate in various outings and activities in the group
home setting, and should be encouraged to participate
in these activities.
3. Records note that church has been a source of support
for AC in the past, so staff should find out if she’s
interested in attending church.
4. See the Occupational Summary and Recommendations
dated 6/27/11 for additional information regarding AC’s
strengths and needs.
RESPONSE TRAINING SYSTEM INVOLVEMENT:
RTS will follow up with weekly contact and onsite consultation during the first 30 days after discharge. The purpose of
this consultation is to assist the placement staff in implementing the RTS/CATU discharge recommendations, and in
maintaining a stable placement for AC. This plan will be
reassessed after 30 days in collaboration with the [group
home[ placement staff.

69

 Placement staff should notify the RTS consultant of any
unusual incidents, deterioration in functioning, further
hospitalizations, involvement with the legal system, or other
concerns about AC’s behavior. Upon deactivation of AC’s
case, the case can be reactivated if a need arises. The RTS
consultant will continue to attend clinical staffings and other
pertinent meetings as deemed necessary.
FUTURE CONSIDERATIONS:
Ideally AC’s placement at XXXXXXXXX Group Home will
allow for her and her family to receive appropriate support
and treatment, so that AC can successfully return home.
[AC’s mother] reports she feels AC will be ready to return
home when she consistently makes positive decisions about
her health and overall safety. It will be essential for [her
mother] to remain involved and feel empowered as part of
the treatment process.
XXXXXXXXXXXXXXJ LCSW,
Response Training System Consultant
XXXXXXXXXXXXXXX M.D.,
Attending Psychiatrist

70

 XXxxxxxxxx XXXXXX

Case # 4: SH
SH, a 15-year-old female ward with moderate mental retardation,
was hospitalized at UHS Hartgrove on 4/27/11 after reportedly
becoming aggressive and exhibiting suicidal ideation in her foster
home placement; her record also shows a six-week admission to
Hartgrove in December 2010.

 
  

Of special note, SH had been a resident of a Maryville Academy
group home serving youths with moderate mental retardation,
where she lived for about two years before being stepped-down
to the foster home setting in 2010; SH is now back at Maryville
following discharge from UHS Hartgrove.
When the UIC reviewers interviewed a senior Maryville official
who was familiar with SH, it was learned that SH herself had
apparently initiated her own re-admission process by phoning
her old Maryville group home from the Hartgrove unit to ask
whether she could return; she complained that hospital staff
were mean to her and that the chaotic environment of the unit
made her anxious. SH’s timing was good because shortly after
her phone calls DCFS reportedly approached Maryville officials
about the possibility of returning her to the Maryville program.
Clinical/Behavioral Management Issues. Despite the fact that
SH’s cognitive limitations were well-documented in her clinical
records, there is little evidence that UHS Hartgrove staff took this
issue into account when developing her individual treatment plan,
nor was there much indication of how hospital staff and clinicians
would provide specific interventions to address the problems that
were itemized on her Master Treatment Plan.
•

From the perspective of the current review of UHS Hartgrove,
then, Problem #1 is the treatment plan itself – or rather the
failure of the treatment team to do little more than construct
the same type of generic or boiler-plated MTP that the UIC
reviewers found throughout a sample of dozens of charts of
DCFS wards admitted to this hospital between 2008-2011.71

•

Moreover, insofar as far as SH is concerned, Problem #2
arises from the destabilizing effect that the often chaotic
environment of the Hartgrove milieu had on this patient –
as demonstrably underscored by the progress notes in
SH’s chart that appear to repeatedly “blame” the patient
whenever she displays certain reactive behaviors.72

71

As noted elsewhere in the current report, federal CMS surveyors recently
identified remarkably similar issues regarding substandard quality of care
and deficits in treatment/discharge planning at UHS Hartgrove [pages XX].  
  

 
  

72

In fact, even progress notes are typically boiler-plated at UHS Hartgrove,
as will be discussed below.

71

 Xxxxxxxxxxxx XXXXXXXX
Psychiatrist progress notes and MTP interventions.
During the first three weeks on the adolescent girls unit at UHS
Hartgrove, SH was reportedly seen 39 times by DR. XXXXXXX,
her attending psychiatrist, most of whose progress notes were
both uninformative and illegible, and who noted virtually the
identical observation about SH on 38 of 39 times, as follows:
“Affect restricted, thought processes are targeted, speech
normal volume. Cont tx plan. Prognosis: Guarded.” 73 74

 
  

Other parts of the psychiatric progress notes for SH were equally
boiler-plated or perfunctory, typically with a few brief words or
phrases describing the patient as “aggressive,” “impulsive” or
“easily agitated.” Similarly, there are no indicators given on the
progress note form about the length of time the psychiatrist spent
meeting with the patient, nor is the box on the pre-printed form
ever checked to indicate the type of service that was rendered.
Moreover, there is little indication in the psychiatric progress notes
about whether SH is achieving even the boiler-plated goals listed
on her individual treatment plan, nor any mention of whether the
treatment team intends to adjust it’s therapeutic interventions to
assist the patient toward that end.
Nursing progress notes and MTP interventions.
Ordinarily, nursing progress notes in psychiatric hospitals are
among the most important documents from which to obtain
reliable shift-to-shift clinical information about how patients are
responding to treatment; under the best of circumstances, the
treatment team would utilize such daily feedback to adjust its
therapeutic interventions as needed. Regrettably, this is often
not the case at Hartgrove, as both UIC and CMS discovered.75
73

The psychiatrist’s observations are repeated essentially unchanged on:
4/29, 4/30, 5/1, 5/2, 5/3, 5/4, 5/6, 5/11, 5/12, 5/13, 5/14, 5/15, 5/18, 5/19,
5/20, 5/22, 5/24, 5/26, 5/27, 5/28, 5/31, 6/1, 6/2, 6/3, 6/6, 6/7. 6/8, 6/9, 6/10,
6/11, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/20 & 6/21.
74

Similarly, the recent report by federal CMS surveyors at UHS Hartgrove
found that all of the charts they examined contained the same “generic and
unfocused interventions” supposedly to be initiated by staff psychiatrists:
"MD will assess & or adjust medications as needed. Order lab work related
to medication"; "Individual psychiatric sessions with patient (number of times
inserted) per week for therapy sessions.”
75

In the same CMS report, surveyors found generic and unfocused nursing
interventions for the problem "Aggression/Violence/Assaultive Behavior”:
"Nursing staff will assess patient for escalating anger/anxiety/aggression
and intervene immediately to protect the patient and others in the milieu";
"Nursing will redirect the patient to a quiet environment if the patient is
agitated or threatening others"; "Nursing staff will monitor the patient for
medication compliance and side effects and effectiveness of teaching
provided q [every] shift." The same generic interventions were found in
SH’s MTP and in charts of other DCFS wards reviewed by the UIC team.

72

 Xxxxxxxxxxxx XXXXXXXX
As was the case in essentially all of the UHS Hartgrove charts
reviewed by the UIC team, however, nursing progress notes tend
to be narrowly descriptive of patient behaviors but generally lack
information relating specific therapeutic interventions by staff to
goals identified in patients’ individual treatment plans.

 
  

At the same time, progress notes for SH were sometimes written
in a tone that appeared to cast blame on the patient when certain
behaviors were manifested on the unit – a problem that was also
noted above in the case of AC, where both the psychiatric and
nursing progress notes suggested she was simply “med-seeking,
demanding or refusing to utilize coping skills.”
A brief sample from SH’s chart is instructive:
•

05.06.11:
“Pt… shows little apparent insight into her behaviors as
being ‘disruptive.’”

•

05.10.11:
“Pt became agitated with a peer who was provoking her in
the hallway. Pt encouraged by staff to ignore & walk away
but pt ran into pt’s room and grabbed pt’s hair and swung
fists at her…Pt showed no insight into her behavior…”

•

05.11.11:
“Pt noted to minimize her aggression yesterday, blaming
peers & noted as slow to follow staff re-direction [about]
verbally attempting to provoke peers from her doorway.”

•

05.10.11:
“Pt has no insight, nor does she want to accept responsibility for her behaviors.”

Other nursing progress notes describing behavioral episodes
involving SH indicted that she was: “sneaky”; “not cooperative
with staff and unable to use any coping skills”; “displays no
insight into behavior issues”; “slow to follow staff direction
or to process her disruptive behaviors with staff.”
Remarkably absent from these psychiatric and nursing progress
notes – as well as from SH’s individual treatment plan – is any
recognition that this patient is cognitively impaired, with an FSIQ
that has reportedly ranged from the mid-60s to the mid-70s.
While basic common sense, to say nothing of clinical experience,
ought to suggest the need for psychiatric hospital staff to take into
account patients’ cognitive limitations – including any problems in
the ability to respond to therapeutic interventions or “show insight”
into their behaviors – that does not appear to be the norm either
in this case or with the other DCFS wards reviewed above.

 
  

73

 Xxxxxxxxxxxx XXXXXXXX

 
  

Of interest, when UIC reviewers discussed SH’s behaviors at
Hartgrove with Maryville Academy officials – who were familiar
with her clinical management issues from her two-year stay in
one of their specialized group homes – they indicated surprise
that she had manifested physical aggressiveness toward others
as such conduct was not typical of her normal interactions with
peers or staff in the Maryville program.
Moreover, in examining the chronology of SH’s behavior on the
UHS Hartgrove adolescent girls unit, it was apparent that for the
first 12 days of this hospitalization she did not manifest any overt
signs of aggressive conduct; on the contrary, she was noted to be
mostly “isolative” to her room and withdrawn from interaction with
staff and peers.
•

Beginning on Day-13, however, the nursing progress notes
indicated that SH was suddenly agitated and aggressive with
peers on the unit [see Item # 78 in the List of 100 incidents
detailed above in Table 1].

•

On Day-19 SH is moved to a room on another hallway due to
problems with peers and acting-out behaviors;

•

On Days-21, 22 & 24 SH spends time in the QR and is now
hitting and threatening peers.

Looking back, Day-13 of SH’s post-admission experience on the
adolescent girls unit was preceded by her witnessing a series of
very aggressive incidents involving other patients, some of which
are also detailed in the List of 100.
•

Specifically, counting forward from SH’s admission on 4/2711
to 5/11/11, there appeared to be no fewer than 13 incidents of
aggressive behaviors or physical assaults on the adolescent
girls unit, as documented by the UIC team in Table 1, above:
see items 52, 53, 57, 58, 59, 62, 65, 66, 67, 73, 74 & 75 [item
74 involved two incidents].

Summary.
Simply stated, it is not unreasonable to suggest that the milieu
environment surrounding this child likely served as a destabilizing
emotional trigger for a patient already vulnerable on many levels,
a recurring issue observed by the UIC team throughout this
review process.
As in the case of AC, the iatrogenic effect produced by countertherapeutic factors at work in this hospital – and a milieu that
often poses psychological trauma or threats of physical harm
ought to be understood in just such terms, as a form of PTSD –
can subvert even the best-intentioned efforts by staff to deliver
appropriate and effective quality of care to their patients.
74

 Xxxxxxxxxxx
•

 
  

Medication issues identified in SH’s chart.
Finally, as was the case with the previous three DCFS wards
examined above, medication consents for SH were delayed
because of the very high deficiency rate by UHS Hartgrove
staff in accurately documenting the consent request forms
that are sent to DCFS for approval.
o

SH’s medication consent was delayed for at least five
days due to missing information on the request form
and the difficulty in obtaining any information from the
attending psychiatrist.
Dr. XXXXX ordered Trileptal on 05/4/11 and the request
was received at the UIC/DCFS consent unit the same day
(at 5:32 PM). The case was assigned for initial review at
9:05 AM on 5/5/11 but could not be approved because
of deficiencies: (1) lack of a rationale for Oxcarbazepine
over Depakote or Lithium; and (2) the need for the MD
to clarify whether the patient was on Seroquel IR or XR.

o

According to the UIC/DCFS consent unit records:
“[UIC/DCFS staff member] made 10 contacts to
obtain this information MD pending 5/11/11 at 5:54
PM; MD pended for rationale for Oxcarbazepine;
made 3 contacts to obtain response to MD pending;
UPDATED information 5/12/11; MD complete
5/12/11; PDF transfer to DCFS 5/12/11 3:30 pm.”
Finally, on 5/13/11 at 9:18 AM the med consent was
able to be approved for the use of Trileptal.
However, the UHS Hartgrove treatment plan review on
5/11/11 noted that consent is needed for Seroquel and
Trileptal, and that there are medication consent issues.
Similarly XXXXXXX’s psychiatric progress note, written
on 5/12/11, states: “Waiting for consent on Trileptal.”
Once again, the miscommunication and confusion that
seems to characterize medication consent procedures at
UHS Hartgrove clearly contributed to unnecessary delays
in this patient receiving her psychotropic medications,
as evidenced by the fact that it took ten phone calls by
the UIC/DCFS consent unit to obtain the missing data;
even then, the attending psychiatrist seemed unaware
that he and the other UHS Hartgrove staff were actually
the locus of the problem.

75

 Xxxxxxxxx XXXX

UHS Hartgrove Staff:
In their own words…

What UHS Hartgrove staff told the UIC Team.
Despite the fact that UHS officials reportedly threatened to fire
anyone even suspected of providing information to the UIC team,
a number of current and former Hartgrove employees, both directcare unit staff and clinicians, reached out to the UIC reviewers,
hoping to share their experiences and frustrations about working
in this hospital.
For our part, the UIC team was heartened by the courage and
dedication these staff showed to serving their patients, and so
we decided to allow them the opportunity to speak about their
experiences at UHS Hartgrove in their own words:76

 
  
 
  
There is just so much
violence, and we feel
so helpless at times.
It never used to be
this way before UHS
took over Hartgrove.

Ø “I am writing to you anonymously for fear of losing
my job at Hartgrove Hospital… but my hope is that
you can help improve conditions here… The main
problem, as you will figure out soon, is that we are
so understaffed on all of the units that no one is
safe, neither the patients or staff… There is just
so much violence, and we feel so helpless at times.
It never used to be this way before UHS took over.”
Ø “When XXXXXXXX [a hospital administrator] told us
last week that UIC was coming to do an investigation
for DCFS, , XXXXXXX said that there would be lots
of extra staff on the units as long as UIC was in the
hospital. One other thing was that they said there
would be “no patients sleeping in the dayrooms on
cots while UIC is here.”

 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  
 
  

“Admitting patients that we do not have beds for is a
common practice at Hartgrove. This has been going
on for at least five years, since UHS bought us. DCFS
wards and [non-wards] are routinely admitted when
we don't have enough beds for them. Usually, they
are slept in cots in the dayrooms. The environmental s

76

The UIC reviewers were contacted by telephone, email, text messages
and personal communication through intermediaries; certain statements
were taken in face-to-face interviews, and in all but a few cases the UIC
reviewers were aware of the actual identities of the informants.
Because some of the specific information provided to the UIC reviewers
could be used to identify these individuals, we have taken steps to minimize
their risk of exposure by withholding or altering certain case-specific details
that appear in the current report; however, many of these individuals agreed
to meet in confidence with the director of DCFS, if requested, to personally
confirm the accuracy of the information they provided to the UIC reviewers.

76

  
  
 
  
 
  
 
  

staff then remove the cots first thing in the morning;,
they roll them down on the elevator to a storage room
by the gym.”
“Once, when IDPH visited Hartgrove, the director of
nursing, xxxxxxxxxxxxxx, ran onto the units yelling:
"Get rid of the cots, quickly, IDPH is here!" 77

 
  
 
  

Ø “There have been many physical assaults on our unit
by patients, mainly patients attacking each other.
Hospital policy is that an incident report should be
written, patients are to be seen by the medical doctor,
parents or DCFS should be notified. Many times this
is simply not done due to understaffing; but staff and
administration tend to ignore a lot, or minimize the
level of violence, so underreporting is common.”

 
  
In morning report we
talked about nothing
except the violence
that occurred over the
weekend…

“The nurses simply don't have the time to do all of
these things. There are two wings to each unit,
housing 22 patients each. Typically, there are only
two counselors assigned to each side. That is a
patient/staff ratio of 1 to 11. Clearly, that is unsafe.”

No one talked about,
or even asked, what
exactly we were going
to do to address the
level of violence...

Ø “Administration tells us that there will be no more
staff assigned, no matter what… We are told that
staffing is ‘mandated by corporate,’ and that no
additional staff will be given to us, that we will just
have to ‘make do’ with the staffing levels we have.
This, of course, is very demoralizing and puts a
major strain on everyone working here.”

 
  
 
  

Ø “We had 46 kids on the unit today, with two more
coming, for a total of 48 patients. We had 8 staff
and a one-to-one, so 7 actually. In morning report
we talked about nothing except the violence that
occurred over the weekend. Many of the kids were
fighting and some got hurt, including DCFS wards.”
“The Program Specialist said it was the worst
weekend he had worked in his life. Not surprisingly, no one talked about, or even asked, what
exactly we were going to do to address the level
of violence… The Unit Manager simply said;
‘Let's get to work.’"

77

Note: the UIC reviewers subsequently met with this writer and two other
Hartgrove staff members who were working on the hospital units the day
this event occurred – later determined from the IDPH report to be 3/4/09 –
and all three staff confirmed the accuracy of this October 2010 email, saying
the director of nursing appeared to be “frantic” and “anxious” that IDPH
would find out about the use of cots to sleep patients in the hallways.

 
  
77

 Ø “The unit is in chaos, with kids assaulting each other
on a daily basis, threatening staff as well. No one,
staff or patients, is safe on that unit. Patients even
made comments to me [expressing their sense of
anxiety] about being on the unit. It is getting out of
control and no one is doing anything about it.”
Ø “I’ve had CPI [restraint training] in two or three other
psychiatric hospitals, so I’m very familiar with the
techniques, but after the initial training [at Hartgrove]
I remember thinking, wow, they must not have very
many restraints here because they sure glossed
over the really important parts of CPI.”
“CPI testing [at Hartgrove] was a joke. At the end of
the training, the instructor said: ‘I’m stepping out of
the room and leaving my book [with the answers]
on the desk. You know you’re not supposed to look
at it. I’ll be back in about ten minutes.’”
“Later on, after I’d worked at Hartgrove for awhile,
a charge nurse on XXXXXXX said to me that ‘if we
had to do the paperwork every time we put hands
on a kid, we wouldn’t get any other work done’ –
so, yeah, what XXXXXXXXX said to you is true:
there is a lot of ‘underreporting’ in this hospital.” 78
“From my experience, 2-North [the adolescent girls
unit] is the weakest unit, with the weakest staff and
leadership. It is not a cohesive team. No one wants
to stand up to the girls, and it feels like the girls are
running the unit sometimes.”
Ø “Today the XXXXXXXXXX told me that [he/she]
also received the re-certification for CPI restraint
training ‘in about 45 minutes, including the test.’
I gave XXXX your number and [he/she] promised
to call and tell you this in person."
“ “XXX also told me that [he/she] witnessed a new
staff member ‘bounce a kid off a wall’ on the unit."
[He/she] went to to XXXXXXXX [a senior hospital
administrator] and reported the incident. XXXXXX
did nothing, and the staff member, who was still in
his probationary period, was allowed to be hired.

78

On follow-up questioning during a later interview, this staff member said:
“At Hartgrove, when they want to give an impression that restraints are low,
they call it ‘escorting.’ You see that all the time [in the nursing chart notes]:
‘patient was escorted to the QR.’ That way they don’t have to write it up as
an actual restraint.”

78

 Ø “As we talked about, not only does HH falsify their
CPI training of staff, giving what is supposed to be
a minimum 3-4 hours of refresher training in only
one hour (or even less), they hand out certificates
at the end saying you just got 3 hours of training.”
“To make matters worse, they also pull staff from
the floor during working hours to do this bogus
training, and no replacement staff coverage is
sent to the units.”
“Yesterday I was told by my Unit Manager: ‘Today
you have CPI re-certification at 3 PM.’ I left the floor
at 3 and returned to finish my work right after 4 PM.
The ‘training’ was completed in one hour, which
included the test, and there was no hands-on CPI
physical hold practice. Oh yeah, at the end we all
took the test orally, so we could write down the
correct answers!”79
Ø “It was a little more than a month ago when I was
looking through a treatment plan on one of my
patients in a certain section of the MTP, the part
listing who was providing the care for that issue,
that I saw that my initials were written in that plan.
But I didn't write them in there.”
“In short, my initials were forged by the Program
Specialist and sometimes by the Unit Manager.
Not only my initials, but the initials of the other
members of the treatment team as well. The
Program Specialist or the Unit Manager were
signing all the initials in the treatment plans.”
“Concerned, I then looked in other charts and
saw that my initials (and initials of other staff)
were falsely entered in almost every treatment
plan. No signatures, just the initials of many of
the [direct-care] staff members.”
“Since the changes spurred by the CMS investigation over the last month or so, the MTPs are
now being done by the social workers, and they
seem to have stopped falsifying people’s initials
in the treatment plans.”

79

During a follow-up interview this employee was asked to clarify, and
he/she responded by saying: “One person reads the question, anyone can
give the answer, and then everyone writes down the ‘correct’ answer on
their [test] sheet. Great system on paper. Not so good in practice.”

79

 Ø When asked during an interview to elaborate on
problems arising from poorly trained staff on the
units, XXXXXXXXX recalled a case from earlier
in the year when a DCFS ward complained that
his arm was twisted behind his back the previous
evening by XXXXXXXXXX, another staff member.
This UIC source said that the unit nurse examined
the boy, noting that his arm was swollen and there
was an abrasion on his left shoulder; the nurse also
gave the ward an ice pack.
When the UIC source told the nurse about the
ward’s allegation of mistreatment by the other
employee, the nurse replied that she had heard
previous complaints about this individual.
Later on during that same shift, the source said,
the nurse came back and suggested that it might
be a good idea if someone surreptitiously [this
was the word used by the source] told the boy
to complain to the hospital’s patient advocate
about the other employee. The source did so.
This interview took place in July 2011, after the
source was allowed by UIC reviewers to examine
a copy of the CMS report on UHS Hartgrove; upon
reading the CMS comments regarding the case of
the boy whose arm was fractured in an inappropriate restraint hold, the source stated that one of
the two staff members in that case was the same
employee involved in this arm-twisting incident.
Ø During a telephone interview a current hospital staff
member was asked to confirm what other Hartgrove
staff had told UIC reviewers regarding “abbreviated”
CPI re-certification; he/she responded by saying:
“Yes, absolutely, that was my experience just last
month, except that I’d say my class was more like
a half-hour if you subtract the time for the test.” 80
80

When asked to describe how the post-test was given, this employee
confirmed what the UIC reviewers were told in previous interviews with
other hospital workers, saying that the questions were read out loud and
discussed, and the class participants wrote down the ‘correct’ answers
on their test sheets.
At the end of this session, this employee said, all the participants received
a “wallet card” indicating they had undergone three hours of approved CPI
re-certification. “Of course, that’s totally untrue,” the employee added,
“and everyone knows it.” 
  

 
  
80

 Most of the session was spent “talking about how
to de-escalate patients,” the employee added,
“which is important, but there was no practicing
CPI restraint holds, and I thought that was a real
mistake considering what happened on the boys
unit a few months ago.” 81
Ø Finally, the UIC reviewers provided both the 2011
CMS report and a draft version of the UIC report on
UHS Hartgrove to a number of current and former
employees to allow them an opportunity to comment
on the findings; all of the staff agreed that the CMS
and UIC reports accurately reflected longstanding
problems at the facility, and they hoped the reports
might serve as a wake-up call to hospital officials
and the UHS corporation.
After reading both reports, one staff member said:
“We deserve better than this, and the kids deserve
better care than we give them… especially for all
the money this company makes off of them.”

81

This comment was made in reference to the case of the youth whose arm
was fractured on the adolescent boys unit in May 2011, as was detailed in
the recent CMS report. According to this employee, at least one of the two
staff members who were later fired as a result of this patient injury received
the same one-hour substandard CPI re-certification as many other hospital
employees, despite what his personnel file might otherwise indicate.

81

 Xxxxxxxxxxxx XXXXXXXX

Accounting for Failure:
Quality of Care Problems
in UHS Hospitals.

 
  

Corporate accountability failures in UHS facilities.
By now, certain facts ought to be abundantly clear from the data
presented in both the UIC and CMS reports about UHS Hartgrove
Hospital; most troubling are the indicators that DCFS wards often
received substandard quality of care and treatment at this facility,
including exposure to harmful iatrogenic effects of a dysfunctional
healthcare institution. Compounding the harm suffered as a result
of such hospital-induced trauma, DCFS wards were also denied
their right to receive effective mental health treatment in a safe
environment – and the human developmental consequences of
that withholding of timely care are simply incalculable.
At issue, then, with regard to the Department’s fiduciary duty of
care, is whether DCFS can have a reasonable level of confidence
about again entrusting the well-being of its wards to a hospital
that has operated in the manner described in the current report;
and here the broader context of corporate accountability for such
a quality failure becomes acutely relevant to understanding the
problems that were identified not only at this Chicago hospital
but at other facilities operated by Universal Health Services.
Toward that end, the UIC reviewers examined available data on
UHS facilities in more than a dozen other states where federal or
state healthcare officials – as well as the Department of Justice –
have taken action because of a pattern of quality of care failures
and harm to patients; for comparative purposes, 12 UHS facilities
in eight states – Virginia, North Carolina, Tennessee, Missouri,
Pennsylvania, Massachusetts, Connecticut and California –
were then selected by way of illustrating the consistency of the
findings about quality of care deficiencies in critical areas:
•
•
•
•
•

Inadequate treatment/discharge planning issues;
Inadequate staffing, including failure to monitor patients;
Violence or risk of harm from other patient safety issues;
Restraint usage issues, including inadequate training;
Clinical care issues, including quality of treatment and
required documentation of treatment services.

Of interest, while both the UIC and CMS reports identified all
of these critical issues at UHS Hartgrove, the identical cluster of
quality performance failures was invariably discovered by federal
or state investigators in these other states (as shown in Table 5
on the following page). Furthermore, these cumulative findings
were not merely random adverse events – the sort of “one-off”
problems that can occur in even the best healthcare institutions
– but were often longstanding quality failures reoccurring after
proffered assurances of corrective action – an object lesson from
which DCFS should draw careful conclusions.
82

 Xxx
Xxxxxxxxx XXXX

Table 5.

Quality of Care Issues in UHS Facilities 82

82

Included in the review of UHS’s California operations was Del Amo
Psychiatric Hospital, in Torrance, California, where a 21-year-old female
patient – a single mother who was admitted following a suicide attempt –
was brutally raped in 2003 as a result of inadequate staff monitoring of the
unit; state records show that the perpetrator was arrested by police and later
pled guilty.
The victim filed a lawsuit against UHS and an attending psychiatrist in 2004,
alleging gross negligence on the part of hospital officials for failing to protect
her from the assailant, a known sexual predator with a history of violence in
psychiatric hospitals and jails.
According to Los Angeles County Superior Court records, UHS asserted
that “defendant’s injuries were pre-existing and exaggerated”; however,
UHS ultimately settled the case in 2006 for $635,000.

83

 xxxxxxx XXXX

Department of Justice actions in Virginia.
While this case was initiated as a Medicaid fraud complaint under
the federal False Claims Act, it is relevant to the current review of
UHS Hartgrove Hospital because it involves a similar pattern of
deficiencies – treatment and discharge planning, understaffing,
poor clinical documentation of care, and inadequate staff training
– as do the other UHS facilities examined below.

Department of Justice
FOR IMMEDIATE RELEASE: March 2, 2010
U.S. Files Complaint Against Virginia Medicaid Providers

 
  

 
  
 
  
 
  

We will not sit idly by
and allow healthcare
providers to take
advantage of troubled
children in order to
feed their own desire
for wealth…
The Medicaid system
was designed to help the
most vulnerable…,
not to line the pockets
of fraudsters.

Department of Justice press release
announcing federal court False Claims
Act filing against UHS in Virginia.

WASHINGTON – The United States and the Commonwealth of
Virginia have filed a False Claims Act complaint in the Western
District of Virginia against Medicaid providers Universal Health
Services Inc., Keystone Marion LLC and Keystone Education
and Youth Services LLC, the Justice Department announced today.
These entities did business as the Keystone Marion Youth Center,
a residential facility in Marion, Va., which receives Medicaid funds
to provide psychiatric counseling and treatment for boys ages 11-17.
The United States’ and the Commonwealth of Virginia’s complaint
alleges that the defendants billed Medicaid for inpatient psychiatric
care that was not provided, in violation of federal and state Medicaid
requirements, and falsified records to cover up their serious
violations.
According to the complaint, the defendants’ actions violated the
False Claims Act. Under the act, a health care provider that
submits false or fraudulent claims to a federal health care program
is liable for three times the government’s damages, plus a civil
penalty for each false claim.
"The Justice Department is committed to ensuring that scarce
Medicaid resources are devoted to their intended use – the
appropriate care and treatment of some of our nation’s neediest
and most vulnerable patients," said Tony West, Assistant Attorney
General for the Civil Division of the Department of Justice. "We
must protect Medicaid from fraudulent practices that deprive
beneficiaries of the quality health care they deserve."
Assistant Attorney General West acknowledged the collaborative
efforts made by the Justice Department’s Civil Division, the U.S.
Attorney’s Office for the Western District of Virginia, the Virginia
Attorney General’s Office, the Department of Health and Human
Services’ Office of Inspector General and the Commonwealth of
Virginia’s Medicaid Fraud Control Unit.
"We intend to prove that these defendants billed Medicaid for
providing troubled children with much needed psychiatric
medical care when, in fact, they provided no such service,"
said Timothy J. Heaphy, United States Attorney for the
Western District of Virginia. "We will not sit idly by and allow
healthcare providers to take advantage of troubled children
in order to feed their own desire for wealth. The Medicaid
system was designed to help the most vulnerable among us,
not to line the pockets of fraudsters."

84

 "The Office of Inspector General has an obligation not only to
protect Medicaid from fraudulent billing but also to protect
mentally ill children from substandard care," said Nick
DiGiulio, Special Agent in Charge for the Philadelphia Region
of the Office of Inspector General of the Department of Health
of Human Services said,
The United States’ and the Commonwealth of Virginia’s complaint
is part of the government’s emphasis on combating health care
fraud. One of the most powerful tools in that effort is the False
Claims Act, which the Justice Department has used to recover
approximately $2.3 billion since January 2009 in cases involving
fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January
2009 have topped $3 billion.

 
  

10-219 Civil Division

Xxxxxxxxx XXXX

United States of America v. Universal Health Services.83

83

United States of America v. Universal Health Services; see list of

attachments for complete amended complaint.

85

 xxxxxxxx XXXX

Actions by state agency officials in Virginia.
Perhaps no UHS facility anywhere in the country has received
more negative attention from healthcare investigators and the
news media than The Pines, particularly after North Carolina
authorities removed their wards from this residential treatment
center following reports of violence, sexual assaults and woefully
substandard quality of care. In April 2011 Virginia officials placed
an intake hold on new admissions to the facility and required that
UHS implement corrective action.
Among the voluminous reports and news media coverage about
chronic problems at The Pines, one Virginia newspaper editorial
asked whether “the most complex mental health cases [should]
be turned over to a company that measures success in profits”
– referring to UHS, and citing the need for increasing staffing
ratios, ensuring the presence of nurses on units and recruiting
qualified therapists.
When the UIC reviewers interviewed sources in Virginia, however,
many in the advocacy community as well as in state government
doubted that such corrective measures would be effective, saying
that “political interference” and “a history of too-cozy relationships”
with hospital lobbyists typically ensured “business-as-usual in
Virginia, even when kids get hurt in the process.”
A brief sample of the reports and news media coverage about
The Pines can be seen below and in the list of attachments.
Xxxxxxxxx XXXX

Consequences at The Pines
April 28, 2011
Virginia has finally imposed meaningful sanctions against The Pines
Residential Treatment Center in Portsmouth and Norfolk, something that
should have happened two years ago.
The Department of Behavioral Health and Developmental Services froze all
admissions to the three campuses for youth with severe mental, emotional
and behavioral problems.
Officials said the decision was based on "ongoing performance issues that
must be corrected to ensure safety and effective treatment for the troubled
children there." North Carolina stopped referrals last week after one resident
said he had been sexually abused by other youths there. That state is
considering removing some or all of its 113 youngsters.

86

 Universal Health Services, which purchased the treatment center last year,
has six months to re-evaluate the mix of children and adolescents it accepts,
particularly ones who are transferred from correctional institutions.
It must improve staffing ratios, make sure nurses are present on each shift,
hire qualified therapists and report all serious incidents to the state. Virginia
has imposed similar requirements in the past on the Crawford campus of The
Pines, but without the admission freeze.
State mental health officials say they want The Pines to be successful
because there are few alternatives available for these young people. But
difficult questions linger.
Is it possible to achieve humane care and positive outcomes in a residential
model that throws together scores of children with serious problems? Should
the most complex mental health cases be turned over to a company that
measures success in profits?
As long as Virginia remains dependent on a handful of large private
providers, will the state ever develop a network of short-term emergency
residential centers and community-based services operated by an
appropriate array of public, nonprofit and private organizations?
Even if it is possible to cure The Pines' problems, it will be an expensive
remedy for state taxpayers.
Since 2006, state mental health inspectors have handled 152 investigations
ranging from minor complaints to serious incidents at The Pines. The new
sanctions require even more intensive monitoring of the three campuses.
At the very least, for-profit companies should be covering the state's cost to
enforce treatment and safety standards. But the better solution is to begin
rethinking how Virginia will take care of its most troubled children.

Xxxxxxxxx XXXX

Sex abuse claim at Pines youth
center investigated
NORFOLK April 22, 2011
Virginia investigators have determined a Norfolk treatment center
for troubled youth failed to properly report and document an
allegation of sexual abuse by a North Carolina resident.
The incident at The Pines Residential Treatment Center, a
private facility that serves youth with mental, emotional and
behavioral problems, was a "peer-to-peer" one, according to
Meghan McGuire, spokeswoman for the Virginia Department
of Behavioral Health and Developmental Services.
The Pines has three treatment centers in Hampton Roads one in Norfolk and two in Portsmouth, licensed for a total of
424 residents.

87

 North Carolina spokeswoman Renee McCoy said the state
has suspended any new North Carolina admissions to the three
Pines facilities, effective April 13, and is reviewing the cases of
113 North Carolina residents currently residing there because of
concerns about patient care, treatment, staffing and training.
The North Carolina families of some residents of The Pines have
been contacted about possible moves.
McGuire said in an email that the allegation was reported by a
boy who stayed at the Norfolk facility, which is on Kempsville
Road and is licensed for 82 youngsters.
The allegation was reported to North Carolina officials after the
youth's discharge on Jan. 31.
The Virginia licensing officials were contacted last week by
the North Carolina Division of Mental Health, Developmental
Disabilities and Substance Abuse Services, according to
McGuire. Officials in that office told Virginia officials a complaint
had been received from the boy's family earlier this month.
McGuire said that North Carolina had not found any proof
of abuse but determined there was enough credibility to the
complaint to take action. Officials there noted the incident had
not been reported by The Pines to state licensing officials in
Virginia and North Carolina, which is a requirement of statelicensed facilities. McGuire said other treatment concerns were
also noted in the complaint.
Phone messages left for administrators at The Pines facilities in
Norfolk and Portsmouth were not returned Thursday.
A report by Virginia's licensing officials completed Thursday said
the facility had violated a regulation that any serious incident be
reported within 24 hours to the agency that places the child in
the facility and to the resident's guardian. The facility also failed
to properly document a January allegation in which the boy said
another resident touched him in his private area, the report said.
Virginia's licensing officials were not informed of the allegation in
a timely manner, according to the licensing report.
The Pines is expected to submit a "corrective action" to the
department by May 11. McGuire said further action by the state
is undetermined at this point.
McGuire said Virginia licensing officials continue to have
concerns about treatment, training of staff, and supervision at
The Pines.
"There are limited residential placement options for children with
severe emotional issues like those the Pines will admit so we
work diligently with providers to make sure they improve and
provide a safe environment and effective treatment for troubled
young people," McGuire wrote in the email. "Over the past
several years, we have encountered significant problems at the
Pines' facilities that have required tremendous monitoring time
by DBHDS licensing and human rights staff. Since concerns
continue to arise despite staff's continual efforts, it may again be
time to reevaluate the status of their license."
The Pines has been the subject of numerous investigations and
citations by the state, which has been struggling to improve its
mental health facilities.

88

 xxxxxxxx XXXX

Actions by state agency officials in North Carolina.
North Carolina’s Department of Health and Human Services
has developed one of the most effective regulatory approaches
in the U.S. with regard to ensuring quality of care and patient
safety, as demonstrated by the intense monitoring and actions
involving two UHS residential facilities: The Keys of Carolina
and Old Vineyards Psychiatric Center.
Over the past several years, DHHS surveys at these UHS-owned
facilities have found evidence of violence, patient abuse, sexual
assaults, improper restraint techniques, staff training deficiencies,
treatment plans not being followed, and failure to report incidents
of harm.84
Perhaps most instructive for DCFS’ concerns about UHS Hartgrove,
however, are the public comments made by the executive director of
Disability Rights North Carolina:

 
  

"Based on both the state review and our independent
investigation, we think The Keys of Carolina is a violent
and dangerous place for children," said Smith, whose
group has a federal mandate to review North Carolina
claims of patient abuse.”
"We have no confidence that the management of this
organization is willing or able to fix any of these issues.
As you can read in the state report, they have been
notified of these problems again and again and again
[since 2009] and have failed to fix any of these very
dangerous practices."

Of special interest, the following sample page from a 2010 report
show that DHHS surveyors determined that The Keys was not
complying with the state’s required minimum 1:3 staffing ratio –
defined as two staff for every three patients at all times – similar
to the DCFS requirement for Illinois residential treatment facilities
serving populations of youths who are categorized as severely
mentally ill or behaviorally disordered.85

84

 
  

After threatening to revoke the facility’s license, North Carolina officials
reached a settlement agreement with UHS that involved a $26,500 fine;
UHS also agreed to conduct more training for staff.
85

As indicated in the earlier discussion of staffing levels at UHS Hartgrove,
requiring a 1:3 ratio for residential facilities but allowing a 1:5 ratio in acute
psychiatric hospital settings is an astonishing failure of public policy that
places children at risk of harm; the UIC reviewers will return to this issue
in the conclusions and recommendations section.

 
  
89

  



 

 

 

 

 

 

 

 
   
 
   
   
   
     
   
   
   
      
  

  

  
       
     
 
     
   
 
     
   

  

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Xxxxxxxxx XXXX

Charlotte mental health
center faces shutdown
April 20, 2011
A private mental treatment center for children in Charlotte
could be shut down after a series of violent incidents,
including the staff hitting patients and a teenager stabbing
another child in the eye with a rusty nail.

State inspectors… found
multiple violations that
‘endanger the health,
safety and welfare’ of
the children…

 
  

 
  

State inspectors who toured The Keys of Carolina in
September and February found multiple violations that
"endanger the health, safety and welfare" of the children,
who range in age from 12 to 17. Many of those housed
there suffer from serious psychiatric problems and are in
the custody of social services agencies from counties
across the region.
The state Division of Health Service Regulation notified
administrators at the 60-bed residential treatment facility
last week that it intended to revoke The Keys' operating
license.
Until that decision is finalized, The Keys can no longer
admit new patients and will be fined $500 a day for each
day it is out of compliance, a bill that now exceeds $80,000.
Efforts Monday to reach Jay Leach, the chief executive officer
of The Keys, were unsuccessful. The facility is owned and
operated by Universal Health Services Inc., a national health
care conglomerate that has run into problems before with
regulators in North Carolina and other states.
'More like a prison'
The head of a Charlotte group that provides legal services to
the children housed at The Keys said advocates have long
been concerned about conditions there. Lawyers for the group
reported they had routinely seen children with bruised faces
and broken bones.
"We have had concerns about that facility ever since it opened
about 10 years ago," said Brett Loftis, executive director for the
Council of Children's Rights. "At many times it has been run
more like a prison than a treatment facility."
State inspectors were called in last year after receiving reports
about an incident in which a 15-year-old was stabbed. According to their written report, the incident was triggered after staff
left notebooks containing information from psychiatric case files
unattended on a table, where they were stolen by a patient.

91

 After reading the files, a teen with bipolar disorder used the
information to tease another male resident about how he was
raped by a family member when he was a toddler. That young
man, who had been removed from the custody of his mother at
age 5 because of the abuse, responded by throwing a chair at
his tormentor.
Tension between the two escalated until Aug. 8, when the boy
who had stolen the records took a rusty nail he had found
outside the facility and jammed it in the head of the other boy,
who had been sitting on a couch watching a movie.

The Keys of Carolina is
a violent and dangerous
place for children…
As you can read in the
state report, they have
been notified of these
problems again and
again and again
and have failed to fix
any of these very
dangerous practices.

According to the report, the nail was more than 3-1/2 inches
long and entered through the left eyelid, barely missing the eye.
The patient was taken to a nearby hospital, where a neurosurgeon removed the nail. The facility failed to report the
incident to regulators despite a requirement to disclose any
patient injury requiring medical attention beyond first aid.
Other reports
The state report, issued Oct. 15 but not shared with the public,
also documented other cases of violence at the facility. In one
incident, a staff member was "horse playing" with a patient, who
fell and hit his head on the floor, leaving a large gash that had
to be stapled shut. In another, a patient with a busted lip
reported that a staff member punched him in the face.
After the October report, the facility was required to submit a
plan to the state for correcting the violations. On a return visit in
February, the state inspectors not only found that the problems
had not been corrected but that there had been additional
violent incidents.
A 123-page report issued by the state March 1 chronicles
dozens of violations, including poorly trained staff and the
widespread failure to adhere to patients' treatment plans.
The staff was also found to be disorganized and lax in
handling patients' prescription medications.
Vicki Smith, executive director of advocacy group Disability
Rights North Carolina, said her group began tracking problems
at The Keys in 2007, after receiving a complaint about the
improper use of force to restrain children. She said the state's
enforcement action against The Keys is appropriate, if not
overdue.
"Based on both the state review and our independent
investigation, we think The Keys of Carolina is a violent
and dangerous place for children," said Smith, whose
group has a federal mandate to review North Carolina
claims of patient abuse. "We have no confidence that the
management of this organization is willing or able to fix
any of these issues. As you can read in the state report,
they have been notified of these problems again and
again and again and have failed to fix any of these very
dangerous practices."

92

 Xxxxxxxxx XXXX

Sunday, May 15, 2011

Universal Health Services facilities
under scrutiny
Youth treatment centers operated by Pennsylvaniabased Universal Health Services have run into
problems in other states, as well. Below are some
examples:
The Keys of Carolina
North Carolina inspectors threatened to pull the license of
The Keys of Carolina treatment center in Charlotte last
year following a series of violent incidents.
Initial Keys complaint
Keys settlement
State inspectors moved in after a 2009 incident in which a
15-year-old was stabbed in the eye with 3 1/2-inch nail by
a fellow resident. The attack occurred after one teen
teased and gossiped about the other having been raped
by a relative as a toddler.
He gleaned that confidential information from staff
notebooks that had been left unattended, according to
state documents.
The facility failed to report the incident to the state as
required when a hospitalization occurs, state officials said.
Follow-up visits uncovered a host of additional problems,
including training deficiencies, improper restraint
techniques and failure to follow treatment plans, according
to state reports.
Inspectors also documented an escape and incidents of
violence, including a patient requiring staples to close a
gash in his head that occurred while he was reportedly
"horse playing" with a staff member.
The state eventually reached a settlement with The Keys
in October that allowed the center to keep operating. The
center, which admitted no wrongdoing, agreed to pay a
$26,500 penalty and conduct more training for staff.
The Pines
Virginia officials moved on April 25 to freeze admissions to
The Pines Residential Treatment Center, which operates
three facilities in Norfolk and Portsmouth for children with
psychiatric and behavioral problems.

93

 Virginia letter to The Pines
The state Department of Behavioral Health and
Development Services also issued a provisional license
for The Pines, a step taken before a license is revoked,
said Meghan McGuire, a department spokeswoman. The
Pines, owned by Universal Health Services, is licensed to
care for 424 children.
McGuire said the moves "are not related to any one
incident, but are the result of ongoing performance issues
that must be corrected to ensure safety and effective
treatment for the troubled children there."
The Virginian-Pilot newspaper in Norfolk reported that the
action occurred after state investigators determined that
The Pines failed to report and document an allegation of
sexual abuse at one of its facilities.
Old Vineyard Youth Services
North Carolina regulators required Old Vineyard Youth
Services in Winston-Salem to correct deficiencies last year
after investigators found evidence of improper sexual
contact between two male teen residents, documents
show.
Complaint and corrections for Old Vineyard
A 14-year-old boy accused his 17-year-old roommate of
forcing him to have oral sex and trying to rape him while
staff members were preoccupied with a disturbance in the
unit, a state report show. Investigators reviewed video
footage that showed the boys engaged in sex acts,
records show, but prosecutors reportedly determined that
the evidence did not warrant criminal charges.
The facility, which did not admit wrongdoing, agreed to
improve monitoring procedures and training for staff.
Several other problems were uncovered during 2009
visits, including medication errors and an allegation that a
patient had engaged in oral sex with a staff member,
reports show. The facility worked to correct the problems
identified and fired the staff member in question,

records show.

94

 Xxxxxxxxx XXXX

Young patients' care left in
doubt
BY MICHAEL BIESECKER - Staff Writer
RALEIGH Dozens of families are scrambling to find suitable care for
their children with mental illness after state officials decided to pull
141 North Carolina youngsters from a Virginia residential treatment
facility following allegations of sexual abuse.
The issue highlights the ongoing lack of in-patient psychiatric
treatment beds in North Carolina and leaves parents facing the
possibility of having to travel even farther out-of-state to visit their
children.
Jeannette Lisching of Clayton is among those with a teenager living
at The Pines Residential Treatment Center in Norfolk, Va.
She received a letter last month from the state Department of Health
and Human Services that said Medicaid payments to The Pines
were being suspended because of concerns about poor supervision
and treatment at the facility, and because of recent allegations of
sexual contact between staff and children and between
unsupervised adolescents.
So far, 90 of the children from North Carolina have been placed in
other facilities, some as far away as Tennessee, South Carolina,
Georgia and Florida.
But 51 children, some of them with intensive needs that can make a
suitable treatment facility difficult to find, are still at the troubled
Norfolk center.
"There are no beds," said Lisching, whose 15-year-old grandson is
at The Pines. "The state is saying they're about to cut off benefits if
we don't move him to a new facility, but there's no place for these
kids to go."
Lisching and her husband adopted her grandchildren, and the
couple travel to tidewater Virginia at least once a month for visits
and to participate in group therapy. The trip takes more than three
hours each way from their Johnston County home.
Renee McCoy, the spokeswoman for DHHS, said the state has
requested that The Pines "take immediate corrective measures to
ensure the safety and treatment of the remaining children."
"DHHS is continuing all efforts to determine and identify beds at
appropriate facilities to transition the North Carolina children who are
currently at the Pines," McCoy said.

95

 Fewer beds in N.C.
In-patient psychiatric beds in North Carolina shrank as part of an
ambitious effort to overhaul the state's mental health system in
2001. State and county facilities were closed or downsized in favor
of a plan that relied on cultivating more outpatient, private treatment
providers.
The result was more than $500 million in state money lost to waste
and fraud. Patients needing crisis treatment are routinely left
languishing for days in emergency rooms waiting for a bed to open
up.
State officials have tried to address the problem by paying private
community hospitals to open more psychiatric treatment beds, but
so far supply has not kept up with demand.
Meanwhile, cuts to the state budget have triggered the closure of
more state treatment beds. Last summer, DHHS closed the last
long-range treatment beds at Raleigh's Dorothea Dix Hospital for
children 13 to 17 with serious mental and emotional disorders.
Private center troubles
Some of the private facilities treating adolescents in-state have also
had problems.
The state moved last year to shut down a Charlotte treatment
center, The Keys of Carolina, after regulators identified multiple
violations after one teen stabbed another in the eye socket with a
rusty 3-inch-long nail.
The Keys remained open after its owners pledged to add staff and
make other significant changes to protect patients.
McCoy said state mental health officials are well aware of the
shortage of quality treatment beds, especially for adolescents.
"We are working to address that," McCoy said.
In March, a Tennessee company announced plans to open 92
treatment beds for children at a new inpatient mental facility in
Garner. That facility is not expected to open for at least a year,
however.
With no suitable treatment beds available in North Carolina, Lisching
fears that her grandson could be placed in a facility even father
away, possibly requiring an overnight trip when she visits.
"Norfolk is already a long haul," Lisching said. "If they move him too
far, it could be a two- or three-day trip. That's tough to do when you
have other kids in school. The state is not doing enough to help
these children."

96

 Xxxxxxxxx XXXX

Actions by authorities in Tennessee.
The death of Omega Leach at UHS Chad Psychiatric Center
was investigated by the Disability Law & Advocacy Center of
Tennessee, the designated protection and advocacy system
for the State of Tennessee. Under federal law, DLAC has the
authority to investigate allegations of abuse and neglect of
persons with disabilities. [See generally 42 U.S.C. §10805
et seq., 42 C.F.R. § 51.41, and 45 CFR §1386.22 et seq.]
While DLAC reports are generally confidential, the agency issued
a limited public report confirming what news media organizations
and other Tennessee sources had learned: “that [the facility]
inappropriately executed a prone restraint of Omega Leach
on June 2, 2007; and “that staff members use restraint [and]
physical holds too frequently and without sufficient grounds
(e.g. restraints are implemented in non-emergency situations
in violation of federal law and facility policy).”
News Media. Ongoing news media coverage – in Philadelphia
as well as Tennessee – revealed troubling details about Omega’s
death, including an array of contributory systemic problems at
this UHS facility that placed other youths at risk of harm:
•

The NBC News affiliate in Nashville obtained an internal
memo showing that “an employee was kept on staff
even though [UHS officials] knew he was abusive to
children,” adding that the facility administrators did not
fire him “because they were understaffed.”

•

According to the Nashville WSMV reporter, who was
interviewed in August by the UIC reviewers, Tennessee
Department of Children’s Services officials had this UHS
facility “on their radar screen” even before the death of
Omega Leach because of “concerns about frequent and
harmful use of restraints.”

•

The Philadelphia Inquirer learned that an anonymous UHS
employee had informed the Department of Human Services
that its wards were frequently being improperly restrained at
the facility; the subsequent DHS investigation showed that
UHS staff “used restraints 1,363 times in a one-year period
between 2006-2007, resulting in 129 injuries and 10 trips to
the emergency room.”

 
  
 
  
 
  

The alarming frequency of restraint usage at this UHS facility over
a protracted period, coupled with the overwhelming evidence of
resultant injuries and even death, suggests a dysfunctional and
abusive culture; that UHS administrators and Tennessee officials
knew about – and by all accounts tolerated – this situation for so
long seems unconscionable.
97

 Editorial: Where's the Justice?
Another day, another $10 million legal settlement
for high-powered plaintiffs' attorney Thomas Kline.
Kline has won a number of eight-figure awards for
clients injured or killed due to negligence or incompetence by businesses, government agencies, and
nonprofit health-care providers.
The latest settlement ends a lawsuit brought on
behalf of Omega Leach, a 17-year-old boy who
died while in the care of the city's Department
of Human Services.
The settlement provides Leach's family with a
financial reward, but no justice.
Leach was one of dozens of troubled teens
DHS sent to a private mental health facility in
Tennessee owned by Universal Health Services
Inc., a hospital chain based in King of Prussia.
A family court judge sent Leach there after he
violated probation by missing a court hearing and
testing positive for marijuana.
At the facility, Leach got into a scuffle with a
worker. A surveillance camera showed the
worker strangling Leach. Witnesses said the
boy was slammed to the ground and banged
into a wall.
Leach died the next day.
Tennessee authorities ruled his death a
homicide. Yet, no criminal charges have been
filed. Instead, DHS stopped sending kids there.
The facility changed names, and the worker left.
An attorney for Universal Health Services says
"no one admits fault." A fat check has been written
in place of the dead boy.
Accountability still awaits.

98

 Xxxxxxxxx XXXX

Memo Reveals Youth Center Aware Of Abuse
Counselor Kept On Staff After Incident
Reported By Nancy Amons
CLARKSVILLE, Tenn. -- A Chad Youth Center internal memo
reveals that an employee was kept on staff even though they
knew he was abusive to children.
John Thomas Boy led a troubled life, according to his mother.
That's why he ended up at Chad Youth Enhancement Center in
2004.
His mother said he was attacked by a resident counselor not long
after his admittance.
"He was strangled, thrown up against the wall, kneed in the groin,”
said Sharon Pruett.
The internal memo obtained by the I-Team shows that the
same resident counselor had done the same thing two or three
times in the past but that Chad kept him on anyway because
they were understaffed.
"I would like for the facility to get shut down, if any way possible,”
Pruett said.
The details are in a Serious Incident Report from the Department of
Children’s Services. The trouble apparently started when Boy
refused to come out of his room.
That's when the resident counselor, Calvin Lee Nelms,
according to the report, picked him up by the collar of his shirt
and threw him against the wall.
Other employees said they had to remove Nelms from Boy.
After the incident, Chad did not fire Nelms. According to
officials, they told DCS they were looking into terminating him
once they found someone to take his place.
More details are emerging about incidents that have happened
at Chad over the years. Two teenagers have died there while
being restrained by the staff.
Russell Kolins is a private investigator working for the family of
Omega Leach, who died in June while a resident at the center.
"There were a lot of incidents at Chad that were investigated at
DCS that were not brought to the attention of the police department,” Kolins said.
Nelms was arrested on suspicion of assault but the case has been
expunged, meaning the records have been destroyed.
That means if Nelms were to apply for another job working with
children, a potential employer would not find any record of this
arrest.

99

 Xxxxxxxxx XXXX

Video Shows Patient In Chokehold
Reported By Nancy Amons 2-25-2010
ASHLAND CITY, Tenn. A videotape that has never been seen
by the public shows the events that lead up to the death of a
17-year-old while he was in custody at a treatment center. The
tape raises questions about the district attorney’s decision
not to file any criminal charges.
Omega Leach died in June 2007 at what was at the time known as
Chad Youth Center in Montgomery County.
The medical examiner concluded Omega died of strangulation
in a homicide.
The surveillance video shot by a camera at Chad shows Omega
and a staff member, Randall Rae, wrestling in a hallway outside
Omega's room. Rae, at one point, has both his hands around
the boy’s neck as Rae has Omega pinned down on the floor.
The altercation would later move to Omega's room, outside of
camera range.
Eyewitnesses said that in that room, another staff member
held Omega face-down in a restraining hold. A nurse then
checked Omega and found he had no pulse and wasn't
breathing.
District Attorney John Carney declined to prosecute either of the
Chad employees. He told Channel 4 he would not comment about
his decision. Terry McMoore of the Clarksville NAACP looked into
the case but had never seen the images from the surveillance
camera.
"I don't see how the district attorney could not press charges, on
this person, right here," McMoore said after seeing the still shots of
Rae's hands around the boy's neck. McMoore said the DA should
have at least brought the case to the grand jury.
David Raybin was Rae's defense attorney.
"It looked for all the world that my client had done something to the
boy," Raybin said.
Raybin said what you don't see in the video is crucial. He said
during the second part of the altercation, in Omega’s room, the
staff tried to cushion Omega’s neck with a piece of foam called an
elbow pad to keep him from banging his head.
"Unfortunately, the elbow pad got underneath his neck, and while
he was being restrained by the other employees, it constricted
against his neck and cut off his breathing," Raybin said.
As for Rae's hands around the boy's neck, Raybin agrees that
wasn't proper procedure. "Certainly, it was not the thing to have
done. But your question here, is, was this criminal? And there's a
world of difference between negligent behavior and criminal
behavior,” said Raybin.
Chad recently settled the case with Omega’s family for
$10.5 million.

100

 WSMV-TV Channel 4, Nashville

86

86

The UIC reviewers wish to acknowledge the assistance of the NBC News
affiliate in Nashville, WSMV TV, for providing the videotape of the restraint
episode that led to the death of Omega Leach in this UHS facility.

101

 XxxXxxxxxxxx XXXX

Actions by state agency officials in Pennsylvania.
UHS Meadows Psychiatric Center.
Pennsylvania officials from the state’s Office of Mental Health
and Substance Abuse Services initiated action against a UHS
residential treatment center, The Meadows, after determining that
the facility presented serious risks of harm to child and adolescent
patients, including: staffing inadequate to provide individual
treatment, high use of restraints, violence and substandard
quality of care. 87
According to a spokesperson for OMH: “inspections found
violations of patient rights, including the excessive use of
restraints or seclusion, frequent understaffing, inadequate
individualized treatment methods, poor record-keeping and
a deteriorating physical plant – the combination of which
created potentially unsafe conditions.”
It should be noted that this facility is located only about 166 miles
from UHS’ headquarters near Philadelphia, making it difficult to
understand how corporate officials could have overlooked these
appalling and longstanding conditions.
Xxxxxxxxx XXXX

State Warns Psychiatric Center
5/22/2011
The state has told a Centre County psychiatric
center it can not admit patients to its child and
adolescent wards until it makes repairs and
addresses several problems pinpointed during
inspections.
According to the Centre Daily Times, the Meadows
Psychiatric Center has closed those wards to deal
with the problems. Several staffers were injured in
February after a riot at the center. Later inspections
found violations of patient rights, frequent under staffing
and a deteriorating physical plant among other issues.

View Video

UHS Meadows Psychiatric Center

87

Selected pages from a 2011 investigative report by the Pennsylvania
Office of Mental Health and Substance Abuse Services are shown below
and detailed in the following article regarding the investigation conducted
by the Pennsylvania Department of Mental Health.

102

  

MEADOWS INPATIENT WW7 LICENSING Inspecnou SUMMARY

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105

Xxxxxxxxx XXXX

Meadows Psychiatric Center plans
upgrades after inspection finds safety
concerns
May 22, 2011 9:09am EDT
The Meadows Psychiatric Center has closed its child
and adolescent wards for renovations after being told
by the state that it cannot admit new patients to those
wards until it repairs and addresses an array of
problems identified during a series of inspections.

Inspections found violations
of patient rights, including
the excessive use of
restraints or seclusion,
frequent understaffing,
inadequate individualized
treatment methods, poor
record-keeping and a
deteriorating physical
plant…

 
  

 
  

A riot in the adolescent ward on Feb. 24, during which
several Meadows staffers were injured, triggered an
investigation by the Department of Public Welfare.
Resulting inspections found violations of patient rights,
including the excessive use of restraints or seclusion,
frequent understaffing, inadequate individualized
treatment methods, poor record-keeping and a deteriorating physical plant — the combination of which created
potentially unsafe conditions for patients, a department
spokesman said.
The findings prompted DPW to place the facility on a
provisional license for the second time in less than a year.
The provisional license is in effect through Sept. 11, at which
time the hospital will be re-evaluated, said DPW spokesman
Michael Race.
The Meadows, in Centre Hall, has separate wards for
children, adolescents, adults and acute care patients, and is
licensed to house up to 101 patients. It is owned by
Universal Health Services, a for-profit, publicly traded
company based in King of Prussia that runs more than
200 acute care hospitals, behavioral health facilities and
ambulatory surgery centers in 37 states.
When contacted about the DPW report and the findings of a
Dec. 30, 2010, report from an inspection by the state
Department of Health, the Meadows first asked the Centre
Daily Times to submit its questions in writing.
The hospital responded to the questions by issuing a
statement that reads, in part:
“The Meadows is in the process of renovating specific areas
of the hospital campus. These facility improvements will
create an enhanced physical and aesthetic environment to
better meet the clinical treatment needs of our patients and
their families. The renovations will take place in systematic
stages, over a 7- month period between April and October of
2011. As such, the Meadows has experienced a conservative
reduction in work force for that same time period that the units
are closed for remodeling.”

106

 The hospital said it is maintaining the staffing ratios
needed to ensure patient safety and comply with state
requirements.
“The management and staff of the Meadows adheres to strict
reporting guidelines outlined in the facility’s Policy and
Procedures and immediately reports any allegations or
incidents to the appropriate state regulatory agencies,” read
the Meadows’ statement. “Due to strict patient confidentiality
and privacy laws, the facility is precluded from discussing the
specific details of any individual patient case.”
Saying there has been “erroneous information circulating
about the hospital,” the Meadows also noted that it is
accredited by The Joint Commission and certified by
the Centers for Medicare and Medicaid Services.
Four former Meadows staff members, some of whom
were laid off as a result of the ward closures, described
their time at the facility as frantic and harrowing, saying
cost-saving measures instituted by administrators
created an environment where patients often acted out
violently against both staff and other patients.
One of them was Kimber Poorman, who served as a mental
health technician in the children’s ward for 15 years before
being laid off on April 7 due to the ward’s closing. She said
she declined a hospital offer to rehire her at a lower salary.
Deteriorating conditions at the hospital made the decision
easier, she said.
“It’s absolutely unsafe,” she said.
Staff levels, turnover questioned
A separate report by the state Department of Health on
Dec. 30, 2010, counted 370 physical confrontations, 13
escapes and 12 patients who inflicted injury upon
themselves, including six suicide attempts, at the
Meadows in a three-month period in 2010.
The report, issued independently of the Department of
Public Welfare’s investigation, was conducted under
authority given the Health Department by the Centers for
Medicare and Medicaid Services. Investigators focused
on the three months between August and October of
last year.
During that time, there were 77 attacks by patients
on staff, and 62 attacks by patients on other patients,
according to the report. At least 26 of the patient-onpatient attacks resulted in injuries. Of the 13 patients
who escaped from the Meadows, four were gone for
more than 24 hours.
The facility “failed to take all reasonable steps to
conform with all applicable state law,” including
regulations pertaining to patient safety, medical care,
record-keeping and staffing levels, the report stated.

107

 Details of the two state reports reveal systemic deviations
from state-approved procedures under which the hospital is
required to operate, especially in the adolescent’s and
children’s wards.
The Department of Health investigation also revealed
frequent understaffing in all wards. The department
investigation found that 56 of 360 shifts between June 1 and
June 30, 2010, were not adequately staffed.
The Meadows, while acknowledging that staffing has recently
been reduced due to the temporary closure of two wards, said
in a written statement that it “continues to meet all staffing
ratios necessary and appropriate to ensure patient safety and
maintain compliance. The hospital takes the safety and
wellbeing of its patients very seriously. Throughout the facility,
all levels of staff are committed to providing the best possible
treatment to our patients in a safe, caring and respectful
environment.”

The facility ‘failed to take
all reasonable steps to
conform with all applicable
state law,’ including
regulations pertaining to
patient safety, medical care,
record-keeping and staffing
levels, the report stated.

 
  

 
  

Poorman staff said turnover at the Meadows has increased
markedly, with at least 100 employees leaving in the past
year, most of them in the past six months.
“The turnover is incredible,” said Erin Schaeffer, a registered
nurse who worked at the Meadows for six months until she
quit in February, citing low pay and concern about unsafe
conditions.
Poorman and Schaeffer were two of four former employees
who agreed to be interviewed by the Centre Daily Times and
made similar statements. Also interviewed was Karen Grieb,
a registered nurse who worked at the Meadows for more
than two years before being fired Feb. 24. The fourth former
employee spoke on the condition of anonymity.
They all said the employees who remain at the hospital have
been forced to work longer hours and are not allowed to call
in sick. Individuals are handling tasks once assigned to
multiple employees, creating a situation that leads to medical
errors, shoddy record-keeping and a lack of adequate
supervision of patients, the former employees said.
The Meadows was placed on a provisional license last year,
from July to October, following a Department of Welfare
investigation that, among other problems, found that new
staff were receiving only two of days of training instead of
the required five weeks. The DPW report said competency
training was being completed in less than 15 minutes, and
safety training was handled in half an hour.
A provisional license is a disciplinary action requiring its
recipient to create and submit to the state for approval a
plan for correcting the problems noted by inspectors, Race
said. At any time, the state can add a provisional clause to
a license, or take it away. The Meadows’ first provisional
clause was eliminated from its license in October 2010,
after the state approved its corrective plan and saw it put
into action.

108

 The Meadows’ second, and current, provisional license went
into effect on March 11.
State finds repairs needed
While the Meadows was often short of staff, its beds
were full. Rooms that should have been used solely for
short-term seclusion were converted into makeshift
bedrooms, containing just a mattress on the floor and
no furniture, and allowing the hospital to house more
patients than its license allowed, according to the
report by the Department of Welfare.

While the Meadows was
often short of staff, its beds
were full. Rooms that should
have been used solely for
short-term seclusion were
converted into makeshift
bedrooms, containing just
a mattress on the floor and
no furniture, and allowing
the hospital to house more
patients than its license
allowed, according to the
report by the Department
of Welfare.

 
  

 
  

Compounding the problem was the Meadows’ frequent
reliance on the process of “cross-boarding,” where patients
were shifted on a nightly basis from one ward to another.
From June 1 to Nov. 24, 2010, the Meadows cross-boarded
patients 1,334 times, according to the Department of Health
report.
The state of the Meadows’ physical plant was another
problem noted by both the former staffers and the DPW
and Health Department reports.
The DPW report found the facility to be in need of
extensive repairs, noting peeled laminate, unpainted
plywood panels in place of cabinet doors in every
bathroom of every unit, visible mold in rooms in three
wards, water damage, rust and black dirt in bathrooms,
dead insects in light fixtures, and walls repaired with wet
or unfinished plaster. Patient rooms and bathrooms were
reported to be cold and the heat in some rooms did not
work.
“It was just falling apart,” Schaeffer said. “Destructive
patients would rip up rooms, some heaters were not
working because patients had ripped wiring and metal
out, so they could have something to cut themselves
or use as a weapon. Patients would punch holes in
walls that would go unfixed — mostly everything went
unfixed or was just given a temporary repair.”
The Department of Public Welfare required the Meadows to
address improvements to the buildings as part of its plan of
corrective action.
“Our first concern is patient safety. Aside from the fact that
no one wants to live in a place that’s not clean, there are
issues of health hazards,” said Race, of DPW.
“Improvements and repairs need to be made.”
Restraint use questioned
The former staffers said that as staffing levels
decreased, staffers began to rely more and more on
restraints and seclusion to defuse tense situations, a
situation also noted in the Department of Public
Welfare report.

109

 “Staffing inadequate to provide adequate individualized treatment as evidenced by the high number of
seclusions and restraints on the child and adolescent
units,” the report said.
Restraint and seclusion and patient treatment issues are
reviewed with heightened scrutiny by regulators in deciding
when to levy sanctions against a facility, due to their potential for threatening patient safety, Race said.
“Restraint and seclusion measures are considered
extreme even when used properly ... (they) are methods
of last resort,” he said.
Between January and October 2010, the number of seclusions totaled 139 in the children’s unit and 148 for the
adolescent unit, while the acute care had 33 and the adult
unit had five.

‘Staffing inadequate to
provide… individualized
treatment as evidenced
by the high number of
seclusions and restraints
on the child and adolescent
units,’ the report said.

 
  

 
  

The state requires administrators to conduct a one-onone review with any staffers involved in the use of
restraints or seclusions within 24 hours of the incident. But state inspectors could find no evidence of
such reviews taking place.
“Lacking information on individual treatment plans in using
seclusion and restraint — there’s a higher level of scrutiny
involved,” Race said. “If you have an adolescent with
history of sexual abuse involved with restraint or limited
mobility, that could trigger a traumatic episode, especially
with children with histories of abuse or neglect. We have to
be careful in treatment plans because you don’t want to
retraumatize them or trigger the trauma that happened to
them in the past.”
The state is requiring the Meadows to address issues
regarding its use of restraint and seclusion and recordkeeping surrounding those events as part of its corrective
action plan, Race said.
Ex-staffers raise concerns
The former staffers all described nearly daily violent
encounters at the Meadows, and frequent emergency
situations, called “codes.”
“Kids getting out of control and hurting staff
happened every day,” Schaeffer said. “Kids would just
grab pretty much anything they could get their hands
on and beat the staff.”
Schaeffer describes being bitten “nastily” by one girl;
another nurse recalls being head-butted; Grieb said a 13year-old boy punched her and another staffer. She also
described a co-worker whose hair was grabbed by a
patient, who then smashed her head into a nursing station,
causing injuries that required seven stitches.
“The company said that it was her fault,” Grieb said. “But
there should have been more people around to help her.”

110

 The former employees said such types of violence are not
unusual at similar facilities, but they said they worried over
the frequency of such incidents and how they were
handled.
The Department of Health report details a list of violent
episodes during the three-month period of 2010 when it
performed its inspection. In one instance, a 15-year-old was
locked in seclusion after punching a nurse and attacking
other Meadows employees with wooden moulding, studded
with nails, that had been ripped off the wall. Staff informed
the inspector that the patient, without provocation, jumped
onto the back of another patient.
In another encounter, a patient broke off a 4-foot-long
wooden piece from their closet and was about to strike a
nurse in the back of her head when stopped by another
staffer. On Oct. 24, 2010, another patient removed a curtain
rod from a bathroom shower and took a female staff
member to the ground in a choke hold.
On Sept. 23, 2010, a 22- year-old “charged a staff nurse and
punched them in the face.”
On Nov. 7, 2010, a 13-year-old patient was “attacked and
repeatedly punched in the head by peers.” The patient’s
mother later requested a discharge, saying she felt the
patient might not be safe at the facility.
On Feb. 24, two boys, ages 17 and 15, and three girls,
ages 16, 15 and 13, attacked several staffers and
damaged property, according to a report issued by
state police at Rockview. Schaeffer said the encounter
started without warning, and got so out of hand that
staff called police, who used Tasers on several of the
adolescents.
The 17-and 15-year-old boys were charged with
aggravated assault, simple assault, riot and criminal
mischief. The 13-year-old and 16-year-old girls were
each charged with riot, and the 15-year-old girl was
charged with criminal mischief, according to a report
issued by state police at the time.
The Department of Health report also highlighted one
incident of sexual misconduct.
On Sept. 19, 2010, a 14- year-old female patient said she
was forced by another patient to have sexual intercourse.
The patient, whom the former staffers described as
having mild mental retardation, was “expansive and
dismissive about the situation and fails to recognize the
significance,” according to the report.
Mike Wolff, an assistant clinical professor of psychology
at Penn State, said violent outbursts are not uncommon
occurrences at facilities treating patients with mental
illnesses.

111

 Without familiarity of the specific events that occurred at
the Meadows, Wolff said inadequate staffing that leaves
patients unsupervised for long periods, such as situations
found by DPW inspectors, increases the likelihood patients
will do harm to themselves or others, and can impair
patient treatment and improvement.
“One of the strongest predictors and risk factors for substance
abuse and conduct- related problems is the degree to which
the child is supervised. The less supervision, the more likely
the kid will be getting into trouble,” Wolff said.
Schaeffer and the other former employees said they agreed
to speak to the CDT not because they’re angry over being
fired or laid off, but out of concern for patients and staff at
the Meadows.
“I loved the kids, and I loved doing my job,” Schaeffer

112

 Xxxxxxxxx XXXX

Federal CMS actions in Missouri.
UHS Two Rivers Hospital has been the subject of federal CMS
investigations and decertification efforts for the past four years,
following repeated failures by hospital and corporate officials to
fully and effectively correct chronic quality of care deficiencies.
The UIC reviewers obtained copies of CMS survey reports from
2008 through 2011 through a Freedom of Information Act request,
most of which showed similar evidence of inadequate treatment
services as the other UHS hospitals examined for this report –
this in addition to similar-sounding corrective action plans as
those submitted to CMS officials in Chicago by UHS Hartgrove.
What was quite striking, however, were the April 2011 remarks
made by an official from the Kansas City office of CMS to the
Kansas City Star: “We have had intermittent issues with other
psychiatric hospitals, but we don’t see them happen over
and over.” Separately, another CMS spokesperson said that
the UHS hospital’s “history of repetitive non-compliance…
demonstrates their inability to ensure the health and safety
of patients.”

Xxxxxxxxx XXXX

113

  

TheiiStaI:

KANSAS CITY STAR

APRIL 8. 2011

After suicides, Two Rivers hospital
faces sanctions

A Kansas City hospital with a history of patient-care
problems failed to admuately monitor a suicidal patient. federal
records show. and then bungled attempts to resuscitate her after
she strangled herself with a strap.

Now the hospital faces federal sanctions.

The March 12 suicide is at least the second at Two Rivers
Hospital since 2008.

Federal of?cials plan to drop Two Rivers from the Medicare
program on Monday unless the hospital has adequate suicide
precautions in place.

The 105-bed hospital at 5121 Raytown Road also faces a June 2
deadline to demonstrate to Medicare that it has taken care of
several other serious problems. including keeping patients who've
committed sex offenses away from other patients.

Termination means the government Medicare and Medicaid
programs would no longer pay Two Rivers to care for patients. The
measure is considered a last resort when medical facilities fail to
meet critical standards.

'Two Rivers disputes any contention that there is an immediate
jeopardy to patient safety.' Kevin Young, the hospital?s CEO. said
Friday in a written statement

'The hospital continues to participate in the Medicare program and
is w0rking diligentty with (Medicare) and the Missouri Department of
Health and Senior Services to demonstrate that the hospital is in
compliance with the Medicare rules." Young said. We have
instituted significant improvements and enhancements in patient
care and safety.?

Medicare of?cials said Friday that they were awaiting the results of
a recent inspection to see whether Two Rivers had improved its
suicide precautions.

If Medicare and Medicaid are terminated. the programs will continue
to pay Two Rivers for 30 days for patients already in the hospital.
but not for new admissions. Provisions have been made to transfer
Two Rivers patients to other hospitals. of?cials said.

 

114

 

Two Rivers is one of just a handful of inpatient facilities
in the area. and beds for people in crisis are in short supply. said
Susan Crain Lewis. president of the advocacy group Mental Health
America of the Heartland.

?Our community cannot afford to lose 105 beds.? Lewis said. ?But
individuals in our community who are struggling with a mental
health issue can?t afford substandard treatment.?

Repeated problems


for-pro?t hospital has had repeated run-inswith Medicare.

'We have had intermittent 
butwedon?tseethem happen overand over.? said Jeri Jackson.an

CentersforMedicareandMedicaid Services.

TwoRivershasfaced Medicare desertification severaltimes before.

of?cials.

Medicare began identifying chronic problems in May 2008. when a
complaint about Two Rivers led to a visit by inspectors. They turned
up an abuse case in which a staff member poured water over a
patient?s head and another in which a nurse put a towel over an
elderly patient's mouth to stop the patient from screaming.
according to inspection reports.

Another visit about six weeks later uncovered cases in which bed
alarms had failed. One patient found on the floor at 3:12 am. had
suffered a broken hip and shoulder. according to the Medicare
reports.

Treatment plans showed that staff had failed to include suicide
precautions fOr a patient who had thoughts of suicide. or physical
therapy for a patient who had recent hip surgery.

In September 2008. an Army soldier committed suicide at the
hospital by using bed linens to hang himself in a closet.

The soldier had been experiencing post-traumatic stress disorder
and had attempted suicide before. That death triggered another
investigation.

After the suicide. Medicare threatened to withhold money from Two
Rivers. But the program agreed to continue paying if the hospital
improved and an outside expert monitored its progress.

Eartyin 2009. inspedors examined medical recordsme Rivers



September 2010. the hospital refused the emergency admission
of a teenager who had threatened to kill someone. Federal law
requires hospitals to see emergency patients.

 

115

 

The teen's caseworker already had signed admission paperwork at
Two Rivers before the police van arrived with the patient. Three
of?cers were needed to restrain the teen. who was placed in
shackles.

Instead of admitting the youth. a staff member told the of?cers to
take the teen to detention. The teen was admitted to another
hospital.

Recent suicide

The case that triggered the current threat of Medicare termination
occurred a month ago.

The 59-year-old woman who took her own life had a history of
depression. hallucinations. paranoid delusions and thoughts of
suicide. She was transferred to Two Rivers from a nursing home on
March 9 after she had asked her ex-husband to leave her in the
woods to die. Two Rivers immediately placed her under suicide
precautions.

Two days later. the patient became very agitated at the hospital.
hitting the bath-room walls.

Two Rivers staff were supposed to check on her every 15 minutes.
But surveillance videos showed that the patient went for 20 to 31
minutes without anyone looking in on her after midnight.

Hospital staff told inspectors that when they checked on the patient.
her blanket was pulled up to her neck. She appeared to be sleeping.
The ?rst sign something was wrong came shortty after 5 am. when
the patient didn't respond when asked to raise her arm for a blood
pressure check. The surveillance video showed the staff member
walking 'casually' to the nurse's station.

Two nurses went to the patient's room. One started CPR while the
other struggled to bring resuscitation equipment.

More nurses arrived at the patient's room. They found the ?rst nurse
doing chest compressions on the patient. The second nurse stood
by. nudging the patient?s feet and saying 'Vvake up. wake up."

Only as staff tried to give the patient oxygen did a nurse discover
the two things around the patient's neck that she had used to
strangle herself. One was the black nylon strap of a wrist support.
The other suicide device was a bright green stretchable ring toy
used to provide sensory stimulation.

By this time. the patient?s face was mottled purple and gray fr0m
lack of oxygen. An automated external de?brillator was brought out
to shock the patient's heart to a steady beat. But it was too late.

 

116

Actions by state agency officials in Massachusetts.
UHS-owned hospitals in Massachusetts have been the focus
of numerous investigations by state healthcare authorities,
particularly Arbour-Pembroke Hospital, a 115-bed facility
serving the Boston Area.

 
  

Of special interest, a 2007 unannounced survey conducted by
the Massachusetts Department of Mental Health found staffing
levels at Pembroke were woefully inadequate and training for
employees was substandard, as noted in the report:
•

“Staffing was inadequate on many occasions,
and ‘short-staffing’ can contribute to a dangerous
environment," the investigators wrote.

Xxxxxxxxx XXXX

State faults psychiatric hospital staff
– Inappropriate behavior cited
July 26, 2007

Pembroke Hospital employees yelled and swore at
patients, engaged in inappropriate horseplay, and
failed to report a patient's stolen credit card on which
$650 had been charged, all in possible violation of state
regulations or hospital policy, according to an investigation by the state Department of Mental Health.
The 142-page report by department investigator Michael
V. Bogosian was completed on May 30. It examined two
whistle-blowers' allegations that patients at the private
psychiatric facility, which draws from across the region,
were being mistreated.
The department also completed a second report in
June. That 10-page document, released Tuesday,
outlines steps the hospital needed to make, including
specific training for workers in how to be respectful
and maintain appropriate boundaries with patients,
and training that focuses on reducing the need for
restraining patients.

117

 That second report, by Michael H. Weeks, the director of
licensing, noted that the hospital on its own already had
identified and fixed many problems. Employees identified
as being disrespectful or abusive are no longer employed
there, he wrote. A new chief executive officer, Elaine Glaser,
was hired in May and "has produced significant
improvements."
The investigation, which began in October and was
completed in May, concluded the following:

Staffing was inadequate on
many occasions and ‘short
staffing can contribute to a
dangerous environment,’
the investigator wrote.

 
  

•

One female staffer had sex with a male patient and
a male former patient, and used cocaine and heroin
while on duty. Numerous other staffers knew about the
drug use but failed to notify the state, as is required.
The woman is no longer employed at the facility.

•

The system for filing complaints against workers
by patients was dysfunctional. Some complaints
apparently never were filed and paperwork was
disorganized. Hospital officials failed to follow up
on complaints.

•

Staffing was inadequate on many occasions and
"short staffing can contribute to a dangerous
environment," the investigator wrote. For example,
in February a nurse was sexually assaulted by a
male patient and another patient needed to come
to the nurse's rescue.

•

The whistle-blower employee at the hospital whose
letter triggered the investigation had asked to remain
anonymous, but the state inadvertently released his
name to the hospital. He still works at the facility.

 
  

In a written statement, Arbour spokeswoman Judith A. Merel
said the hospital had made strides to address the problems
raised by the state, such as hiring a new chief executive,
Elaine Glaser.
The hospital also has hired a new human rights officer,
who reports directly to Glaser and tracks complaints and
incidents; has beefed up training in crisis intervention; and
reinforced its policies on employee conduct and work rules,
such as inappropriate contact and language with patients.
All identifying information about patients and employees, as
well as medical information, was redacted in the public copy
of the investigation. More than 40 people were interviewed
by the investigator.

118

 The investigation began last fall when the department
received a letter from a hospital employee, stating the
hospital housed a "prevailing atmosphere of disrespect
and disregard for appropriate psychiatric care" and a
"culture of hostility and disrespect ... perpetuated by
the approach that many staff, both [mental health
associates] and RN's, seem to take toward patients
that involves yelling and swearing."
A former employee later sent an e-mail and letter alleging
that a worker was having sex with patients and was using
cocaine and heroin.
The private psychiatric hospital has 115 beds and is a
division of Arbour Health System, whose five psychiatric
hospitals and outpatient facilities make it the largest provider
of its kind in the state. Pembroke offers inpatient evaluation
and crisis intervention for teenagers, adults, and elders with
mental illnesses and addictions.
Pembroke Hospital's chief executive officer, Paul Zani,
resigned in March amid several investigations. The US
Occupational Safety and Health Administration opened an
investigation after a report of patient assaults on employees,
but it was closed without a finding of violations.
The state Department of Social Services also initiated
investigations related to alleged problems in the girls'
adolescent unit. One investigation was closed without a
finding and one is still open, Merel said.
After a surprise visit in March from the state Department
of Mental Health, the hospital agreed to cap its admissions after the department determined the facility had
staff for only 81 patients. The hospital plans to ask the
state in August to increase the allowed number of beds
to about 90, Merel said.
The investigation completed in May found that mental
health workers and nurses yelled and sometimes swore
at patients. Staff would engage in inappropriate behaveior such as slapping buttocks, and backs of heads,
or flicking ears, the investigation found…

119

 xxxxxxxx XXXX

Actions by state agency officials in Connecticut.
Connecticut authorities and child welfare advocates have tracked
repeated problems at UHS Stonington Institute for years, and in
2006 the state’s Department of Children and Families finally
closed admissions to the facility, in part reportedly because of
UHS’ failure to honor the staffing levels it had promised in 2004
(when it purchased the facility).
DCF itself later came under criticism from child welfare advocates
– and the state’s attorney general – in 2008 for reportedly failing
in its oversight/enforcement role when it was discovered that
UHS had continued to understaff the facility, failed to properly
train staff, provided inadequate clinical treatment and put children
at risk of harm.
Holding aside any questions about specific quality deficiencies,
what is indisputable is that UHS repeatedly failed to fully comply
with standard quality of care requirements at this facility for nearly
five years, from 2004 through 2008, during which time it became
embroiled with Connecticut authorities (including the attorney
general) and child welfare advocacy organizations, in addition
to news media coverage of its failures from the Hartford Courant
to the New York Times (as seen in the articles below).

 
  

Xxxxxxxxx XXXX

State Halts Treatment Center
Admissions
Concern For Safety Of Children Prompts Move
August 03, 2006   By COLIN POITRAS; Courant Staff Writer

State officials have stopped sending children to a
substance abuse treatment center run by former state
Sen. William Aniskovich because of concerns about the
children's safety and supervision. The state Department of Children and Families shut off admissions
to the Stonington Institute on July 13th. The 45-bed
Institute, located in North Stonington, helps children
ages 13 to 17 deal with substance abuse and mental
health issues…
DCF spokesman Gary Kleeblatt said the agency closed
admissions after receiving reports of a high number of
children running away from the program. The facility
averaged two runaways a day in the first two weeks of
July, Kleeblatt said.

120

 Kleeblatt said the runaways were a symptom of the
children not being properly supervised and engaged.
Site visits last month confirmed that the program
was not maintaining the staffing levels it promised
when DCF extended the facility's license in
November 2004, he said.
The program is supposed to have at least three staff
members on duty per housing unit during the second
shift and two on duty during the third shift, yet records
showed levels often varied and were not always met,
according to DCF documents.
Kleeblatt said DCF will reopen admissions once it is satisfied
the children's needs are being met. Despite its concerns,
DCF is not removing any children from the inpatient residential treatment center…
Officials at DCF have had trouble with Stonington
Institute before. In 2004, DCF was forced to renegetiate its multimillion-dollar contract with the facility
after concerns were raised about approximately
$500,000 in unexplained costs billed to the state.
That same year, Stonington Institute and its associated programs in southeastern Connecticut were
purchased by Universal Health Services, one of the
country's largest and fastest growing for-profit
hospital chains, for $40 million.

Xxxxxxxxx XXXX

DEFICIENCIES IN TREATMENT OF YOUTHS AT
STONINGTON INSTITUTE PERSIST
Critics Says State DCF Failing In Its Oversight Role
Hartford. In 2006, a team of state inspectors halted admissions to the adolescent drug-abuse treatment programs at
Stonington Institute, saying the private facility had woefully
insufficient staffing, poorly trained workers and a dim
concept of the remedies it was being paid to provide to
troubled youths.

121

 Now, after nearly two years of monitoring by state agencies
and assurances from Stonington Institute's management that
it is correcting those problems, the facility's critics say there
has been little meaningful improvement -- and that the state's
own Department of Children and Families has failed to
exercise aggressive oversight of a program in which it
places struggling kids.

 
  
The people who actually
care for the kids…
had absolutely no
training germane to
the needs of the kids
that they were being
asked to serve…

Stonington Institute is now the subject of parallel investigations by state Child Advocate Jeanne Milstein and Attorney
General Richard Blumenthal, both of whom expressed
concerns last week about the strength of supervision
currently being provided by DCF.
Those charges provoked a vigorous defense from the childprotection agency, where authorities said they are doing
their best to sustain improvements in the Stonington
Institute program, which serves a narrow but vital niche:
treating young people with both mental health and substance abuse problems.
But the agency's patience seems to be flagging, as some of the
violations for which DCF cited the program in 2006, and as far
back as 2002, have surfaced again and again.
"They've been under a microscope for a while," said Louis Ando,
the chief of DCF's Bureau of Continuous Quality Improvement, in
an interview last week.
Upset last month by what they saw as back-sliding on some of
the violations first identified in 2006, including inadequate staffing
levels and quality of treatment, DCF officials called in executives
from the institute and its parent company, the Pennsylvania-based
private hospital chain Universal Health Services Inc., or UHS,
Ando said.
Stonington Institute executives and UHS "had been working on
some of these issues for an extended period of time, and we had
seen improvement plateau," Ando said. But the meeting ended
with the agency at least partially reassured.
Stonington Institute has recently brought in a new operating officer
and clinical director, Ando said, and DCF officials are hopeful. The
facility -- licensed for 45 beds -- is currently limited to 27, but with
the potential to grow back to its original size, with approval from
the department and if no more violations are found.
There were 21 clients living there as of last week. "I thought that
we were uncharacteristically unkind," Ando said, "in that we said,
'Tell us how this is different. Tell us what you're going to do.' And
we came up with a few reasons why we think we're at a point
where they can make some kinds of improvements. That doesn't
necessarily mean that we have stopped our monitoring."
That doesn't sit well with critics like Milstein.
"DCF can sometimes be a very irresponsible parent,"
Milstein said, in an interview, along with Mickey Kramer,
the associate who has led her staff's investigation of

122

 Stonington Institute. "Responsible parents would not put
their child in a place that continues to be a problem. It's one
thing if there's a problem and the problem gets solved, but
this is two years later. Responsible parents don't do that."
On July 7, 2006, a team of inspectors and licensing officials from
DCF and the Department of Public Health arrived unannounced at
the main residential campus of Stonington Institute, on Swantown
Road in North Stonington.
They did not like what they saw. According to a review of its
findings, the team found an eager but inadequately trained staff,
poor supervision of the mentally ill and substance-addicted clients
living on the premises, and significantly lax security. Though it is a
residential drug-treatment center, Stonington Institute did not then
have on staff a single "master's level" clinician or a licensed drug
and alcohol counselor, the team found.
Perhaps most damning was its review of the facility's
"program model/philosophy" for treatment. While Stonington
Institute's executives claimed to abide by a number of
different treatment models, the summary's authors wrote,
"there is no evidence that training in these modes of care has
been provided, that the treatments are delivered with fidelity,
that integration of the models has been achieved at either a
conceptual or a practical level, or that the clinical staff could
adequately describe the model, much less deliver it
effectively."
In the intervening months, DCF and DPH officials have conducted
frequent site visits and extensive negotiations with the facility's
executives. Those have produced some success, DCF officials
said.
But some of the agency's efforts are seen as laughably minor
by critics like Kramer, of the child advocate's office, and
Blumenthal.
One such instance could be found in the voluminous reports
that Stonington Institute filed with DCF to document progress
on the corrective action plan adopted after the 2006 violations
were uncovered. The status report was among a large number
of records and site visit reports obtained by The Day under
state open records laws.
The report outlines efforts to correct the fact that staff
members had been previously unschooled in the institute's
model for treating children in its care this way: A team of
staffers, the document says, "met on 11/30/06 and began
research of the model via the internet."
"The people who actually care for the kids, which is, you
know, the vast majority of hours in the day, had absolutely
no training germane to the needs of the kids that they were
being asked to serve," said Kramer, who made a site visit in
the spring of last year, months after that update report was
sent to DCF. (The child advocate's office was never informed
of the initial 2006 violations, she noted.)

123

 "There is no treatment occurring," she said. "And that is
not to say that they don't have some highly qualified,
well-intended practitioners working within that program,
but there's no program to operate from."
Stonington Institute has attributed many of its problems to staff
turnover. Amid frequent staff turnover, it is difficult to get new hires
trained and ready to work with clients, executives have said, in an
argument that Ando and DCF said they received with sympathy.
DCF officials have also distanced themselves from what they
feel is the child advocate office's overly aggressive approach
to programs, like Stonington Institute's, that attempt to right the
lives of deeply complicated and troubled kids, often with imperfect
methods and results.

We get comments from
[UHS] staff all the time,"
[the state trooper said]…
'Oh, Trooper, thanks
for coming up. Our
management won't
give us this, they won't
give us that…'
Those are the things
they are telling us.

"We know that these kids are not, you know, dropouts from the
Mormon Tabernacle Choir," Ando said. "We know that they're in
these programs because they have significant issues. And we
know that those issues are not going to go away by nature of
their magical admission to a particular program."
The child advocate's role, he added, "is to hold up that mirror and
to say 'This is the "perfect" and you should be doing it.' And our
role is to strive towards the perfect without holding the good
hostage."
Kramer, the associate child advocate, offered an indignant
rebuttal. "If you were the parent of one of the 21 kids, and you
found out about this, what would you think?" she said. "You want
to leave your child in there in that program, in that program that's
struggling to just stay alive?"
The enforcement actions have cut into Stonington Institute's
bottom line. The facility received roughly $4.8 million in payments
from DCF in both the 2005 and 2006 fiscal years, but that number
dipped to roughly $2.6 million in fiscal 2007 -- reflecting the first
admissions restrictions imposed by the state.
A request for comment on this article from Stonington Institute was
referred to a regional spokeswoman for its parent company, UHS.
Stonington Institute officials have been "working closely" with DCF
and the public health department, said Judith A. Merel, a regional
director for community relations at UHS, in an e-mailed statement."
Over the last year, Stonington has effectively addressed issues
raised by these regulatory agencies, and continues to work
collaboratively with them for continued quality improvement,"
the statement said. "There are currently no licensing actions that
are in place from any external regulatory agency indicating their
concurrence with the overall quality of inpatient and residential
substance abuse psychiatric programs."
But that statement was immediately contested by DCF.
"There's clearly concerns we've got about the program,"
said Gary Kleeblatt, the DCF communications director.
"I don't think we could have made it any clearer."

124

 Kleeblatt said DCF officials were surprised by Merel's contention
that there are no "licensing actions ... in place," and cited some of
the very measures that DCF has offered as proof it is exercising
oversight, including its restriction on the number of children who
may be admitted to Stonington Institute, its departmental review of
any clients before they may be admitted, and its three weekly visits
to the program -- "far more than normal" for a treatment facility not
under scrutiny.
Meanwhile, others wonder how such staffing problems -including a 2007 settlement with the U.S. Department of
Labor for failing to even pay workers the minimum wage -could afflict an institution with such a profitable corporate
parent.
"There is clearly a responsibility, moral if not legal, on the
part of the parent company," said Blumenthal, referring to
UHS.

There is clearly a
responsibility, moral
if not legal, on the part
of the parent company,"
said [Attorney General
Blumenthal, referring
to UHS.

The company, based outside Philadelphia, which bills itself as the
third-largest hospital management chain, has experienced a boom
in business in recent years, despite a revenue loss tied to damage
from Hurricane Katrina. The company reported record revenues of
$4.2 billion in 2006, according to a report to shareholders, a 7
percent increase over the previous year.
Among the company's directors is former U.S. Sen. Rick
Santorum of Pennsylvania, who was the third-ranking Republican
in the Senate before his defeat in 2006.
UHS, said Blumenthal, "certainly has resources to assure
compliance with standards of quality care as well as legal
mandates. There's no excuse for delay or substandard staff or
care. So the answer is, most definitely the parent should be held
accountable."
That's the same thing some more up-close observers were
saying this week, including Trooper Victor Lenda Jr., a
resident trooper in North Stonington who has complained
to Stonington Institute executives in the past about the time
and energy police have spent responding to calls generated
by the facility.
"We get comments from staff all the time," Lenda said.
"'Oh, Trooper, thanks for coming up. Our management
won't give us this, they won't give us that, we can't get a
hold of management sometimes.' Those are the things
they are telling us."
Lately, Lenda said, "the staff has been doing fine. I think management could be doing better."

125

 Xxxxxxxxx XXXX

News

DCF blasted on oversight at
treatment facility
Sunday, October 19, 2008
Associated Press
Two state officials are blaming the Department of Children and
Families for not properly overseeing a facility where teens being
treated for drug abuse and mental illness were involuntarily
injected with medications.
Staff at Stonington Institute in North Stonington used the medications
this spring to restrain at least five boys, about 16-years-old, who were
considered to be out of control.

…Attorney General
Blumenthal wrote…
that DCF should have
discovered the involuntary injections…
sooner so fewer
children would have
been ‘assaulted with
needles.’

Child Advocate Jeanne Milstein and Attorney General Richard
Blumenthal wrote to the commissioner of the child protection
agency that DCF should have discovered the involuntary injecttions of “intramuscular medication” sooner so fewer children
would have been “assaulted with needles.”
The practice of involuntary injections has been stopped and no lasting
harm to the teens has been reported. But Milstein and Blumenthal
wrote how, “once again we see evidence of DCF’s inability to demand
and oversee the delivery of effective, safe services for children.”
A DCF spokesman said the agency handled the situation promptly and
effectively.
“DCF quality improvement staff discovered the use of involuntary
administration of medication, and our medical staff responded by
going to Stonington to instruct them to immediately discontinue
this practice, which involved a few instances,” agency
spokesman Gary Kleeblatt told the Hartford Courant.
He said DCF called the executive director of Stonington Institute’s
corporate parent and the institute’s chief executive officer to
emphasize that such injections were unacceptable and to make
sure the practice had stopped.
The facility houses fewer than 20 children, about half sent by DCF,
according to Milstein’s office.
The criticism of DCF from Milstein and Blumenthal comes shortly
before two legislative committees will hold an investigative hearing
today to discuss the agency’s operations.
Lawmakers convened the hearing after negative news about DCF over
the summer, including the death of an infant who was a foster child
under a DCF worker’s care.

126

 In their letter, Milstein and Blumenthal told DCF Commissioner
Susan Hamilton they are in the preliminary stages of an investigation into Stonington Institute, but they are already “gravely
concerned about the safety and care of the children who remain
in residence there, despite chronic program deficiencies that
have long been identified by DCF.”
The facility houses fewer than 20 children, about half sent by DCF,
according to Milstein’s office.

Xxxxxxxxx XXXX

Hartford: Back Wages Settlement
B

THE ASSOCIATED PRESS
Published: July 17, 2007

A behavioral health care organization and its
parent companies have agreed to pay more than
$1 million in back wages to 143 employees, the
federal Labor Department said yesterday.
The company, Stonington Behavioral Health in
North Stonington, doing business as Stonington
Institute, and its parent companies, Universal
Health Services and U.H.S. of Delaware,
were accused by the federal agency of paying
employees less than the federal minimum and
overtime wages.
A spokesman for Stonington Institute did not
return a phone call seeking comment yesterday.
The companies agreed, without admitting liability,
to a consent judgment to resolve the matter, the
Labor Department said.

127

 Xxxxxxxxx XXXX

Federal CMS & state agency actions in California.
Southwest Healthcare System.
UHS-owned Southwest Healthcare System, a general medical
center in Southern California, was found in repeated violations
of federal healthcare regulations between 2007-2010, finally
resulting in CMS initiating action to terminate the hospital’s
certification for Medicare and Medicaid reimbursement. Further,
after accumulating the highest number and largest amount of
fines ever assessed by state officials, the California Department
of Public Health gave notice in 2010 that it intended to revoke
the hospital’s license to operate.
As one healthcare newspaper asked about this UHS hospital:
“How could so much be so wrong?” – not an unfair question,
actually, in light of significant quality failures over several years:
•

lack of adequate numbers of on-call physicians;

•

nursing staff failures to administer medications as ordered
by physicians;

•

infection control and sanitation problems (including mold
found growing in delivery rooms);

•

pharmacy problems that posed risks of harm to patients.

Many of these problems – some of which surveyors considered
serious enough to be “immediate patient health jeopardy” issues
– emerged even after a federal monitor was assigned and UHS
officials had signed a consent agreement.
Most important to note, the CMS termination letter to UHS officials
put the matter bluntly, saying that not only did “many previously
identified systemic problems persist, but the survey also
documented the inability of the hospital’s governing body…
to take appropriate measures to eliminate clear threats to
patient health and safety.” 88
88

Remarkably, the then-CEO of UHS Southwest made a number of public
comments indicating that the federal and state actions were pro forma and
not all that serious, saying “this, too, shall pass.”
UHS corporate officials, however, appear to have finally gotten the message
that the previously expectable “cost of doing business” in California had just
risen; the hospital CEO was soon disappeared and replaced, and outside
consultants were sent in by UHS-corporate to reorganize all aspect of the
hospital – and, by all accounts, to quickly make peace with the federal and
state healthcare officials.
. 
  

128

  

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is so Statement ?De?ciencies. Form CNS-2567.

The date on which the WM terminates is lune l. 2010. The Medicare program will
not make payment for Inpatient hospital services furnished to patients who are admitted on
or alter line I. 2010. For patients admitted prior to lune l, 2010. payment may continue
to be trade for a maximum of 30 by: ol inpatient hospital services on or alter lane 1. 2010.
You should submit as soon as possible. a list of names and Medicare elaint numbers ol
bene?ciaries in your hospital on lane 1. 2010 to the San Francisco regional of?ce to
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Appeals Board
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129

Xxxxxxxxx XXXX

Key Dates/Timeline Southwest Healthcare System
The following are key dates in the failure of Southwest Healthcare
System to meet federal patient care standards.
June 2007 – Surveyors from the U.S. Center for Medicare and
Medicaid Services (CMS) found during a complaint investigation that patients were in immediate jeopardy because there
were insufficient on-call physicians. The survey revealed noncompliance in three Medicare Hospital Conditions of Participation.

 
  

The hospitals failed to provide adequate on-call physician
coverage to meet the needs of 16 of 124 patients needing
emergency services. Treatment of some of the patients with
life-threatening injuries was delayed by up to eight hours. An
administrative penalty based on this survey was later issued to
the hospital. CMS ordered a full validation survey as a follow-up
to this investigation.
October 2007 – During the full validation inspection, surveyors
found a total of 13 Medicare Conditions of Participation not met,
placing more patients in immediate jeopardy in two ways. First,
inadequate emergency supplies of medication were available to
treat life-threatening medical emergencies. Second, the hospital
failed to ensure proper food control, placing patients and visitors at
risk for serious harm due to the potential growth of microorganisms
and food borne illness. An administrative penalty was later issued
based on the second immediate jeopardy. A re-visit was later
ordered by CMS.
June 2008 – California Department of Public Health (CDPH)
surveyors found during a complaint investigation that Intensive Care
Unit patients were being placed in an illegal “satellite” unit and not
properly staffed. Patients were placed in immediate jeopardy
and the hospital was issued a cease and desist order. An
administrative penalty would later be issued based upon this
complaint investigation.
July 2008 – During the re-visit, a total of four Conditions of
Participation for Medicare were not met. A second revisit was
later ordered by CMS.
March 2009 – During the second revisit, a total of seven
Conditions of Participation for Medicare were not met.
May 2009 – CDPH surveyors attempted to help Southwest by
performing a courtesy survey on the unlicensed Woman’s Center
and Emergency Departments. Surveyors discovered a lack of
temperature monitoring system in the surgery area, which was
placing patients in immediate jeopardy. CMS ordered CDPH
surveyors to conduct a complaint survey which resulted in the
temporary closure of the surgery area.
July 2009 – Under pressure from CMS, Southwest hired a Quality
Monitor consultant to identify and address issues of noncompliance.

130

 August 2009 - CDPH surveyors initiated a complaint investigation
regarding the discharge of an infant with elevated bilirubin levels
from Inland Valley Medical Center. The baby has since shown a
delay in neck movements and tracking of objects and will now be
followed by Occupational and Physical Therapy. This investigation
resulted in an immediate jeopardy situation being found. Three
other infants were affected by the hospital’s failure to take appropriate action when bilirubin level risk factors were identified. (One
administrative penalty was issued April 13, 2010, related to this
bilirubin investigation.)
September 2009 – While monitoring the hospital after it stated the
bilirubin problem was corrected, CDPH surveyors found babies
being discharged who were assessed as at risk for hyperbilirubinemia without appropriate follow up for a pediatrician consultation or
further lab testing. Patients were again being placed in immediate
jeopardy. (A second administrative penalty related to bilirubin was
issued April 13, 2010.)
October 2009 – Southwest Healthcare System self-reported low
humidity levels in the operating rooms at Rancho Springs Medical
Center. A state and federal survey team investigated. This investigation resulted in a federal immediate jeopardy situation being found
after it was determined that three elective Cesarean Sections were
conducted under conditions which could have resulted in a fire. (An
administrative penalty related to this incident was issued April 13,
2010.)
December 2009 – CMS sent a letter to the Board of Directors
and President of Universal Healthcare, Inc. (Southwest Healthcare’s parent company), to express concern with the hospitals’
ability to pass the upcoming full validation survey.
The survey was billed as a “make-or-break” inspection.
January 2010 – Full validation survey initiated.
April 13, 2010 – Three administrative penalties issued to Southwest
Healthcare System (see above).
April 15, 2010 – Results of the January 2010 full-validation survey
are released to Southwest Healthcare System. CMS issues a termination letter to Southwest Healthcare officials notifying them that
their enrollment in the Medicare and Medicaid Programs will be
terminated effective June 1, 2010. Federal reimbursement will not
be provided for patients admitted after June 1, 2010 but reimbursement will continue for 30 days for those patients admitted prior to
June 1, 2010.
April 19, 2010 – CDPH released to Southwest a letter informing
the hospital that CDPH intends to proceed with a license
revocation action. This action is based on repeated failures to
comply with state licensing laws and regulations. The hospital has
an opportunity to appeal this action. The revocation process generally takes between 12 to 18 months to complete but at any time
Southwest or CDPH may enter into settlement discussions to
resolve the revocation action.

xxxxxx

131

 Conclusions regarding UHS Hartgrove Hospital.

Conclusions &
Recommendations

The cumulative weight of the available data regarding services
provided to DCFS wards at UHS Hartgrove Hospital demonstrates
a consistent pattern of unacceptable risks of harm, substandard
quality of care, poor clinical treatment and discharge planning,
and questionable clinical management practices by hospital and
corporate officials at all levels of the organization.

 
  

Moreover, the Department should be especially concerned by
certain findings regarding the clinical operations of this hospital:
the existence of a chaotic and frequently violent milieu in which
DCFS wards were placed at risk of harm; understaffing of the
inpatient units; a history of overcrowding of the inpatient units,
including sleeping children on cots in the hallways or dayrooms;
and inadequate staff training, including evidence UHS officials
misrepresented data about training/recertification in the use of
restraints and behavioral intervention methods.
While the findings by the UIC team during the course of its review
at this Chicago Area hospital are troubling, it should be instructive
for DCFS that a nearly identical cluster of quality of care failures
was routinely observed in other UHS facilities, as shown in reports
by state and federal healthcare officials across the U.S. and in a
recent federal court complaint by the Department of Justice:
•
•
•
•
•

Inadequate treatment/discharge planning issues;
Inadequate staffing, including failure to monitor patients;
Violence or risk of harm from other patient safety issues;
Restraint usage issues, including inadequate training;
Clinical care issues, including quality of treatment and
required documentation of treatment services.

Of particular relevance, therefore, is the abundance of evidence
from these other states indicating that such problems at UHS
facilities tend to reoccur with alarming regularity. In fact, when the
UIC reviewers interviewed sources in a number of state agencies
that had tracked various UHS hospitals or residential treatment
centers over a period of years, there seemed to be a consensus
about why these critical problems were never fully resolved: on the
one hand, we were told, local facility administrators often appeared
to lack basic knowledge and management skills to address such
difficult issues; on the other hand, some observers felt that UHS
corporate-level management/financial expectations made effective
and sustainable problem-resolution unreliable at best.89
89

One state agency official used the term “intransigence” to describe the
repeated failure by UHS corporate officials to own up to their unwillingness
or inability to provide adequate resources and leadership for a hospital that
had been “teetering on the brink” for a number of years. Indeed, the former
attorney general of Connecticut put the question in terms of “a moral, if not
legal, responsibility” of UHS officials to meet their obligations to patients.

132

 Xxxxxxxxx XXXX

 
  

Further, while the UIC reviewers and CMS surveyors separately
concluded that much of what passed for treatment planning at
UHS Hartgrove tended to be generic or boiler-plated paperwork
exercises, often with marginal value to the needs of patients and
typically disregarded in practice by hospital staff, the evidence
about troubled UHS facilities around the country suggests that
boiler-plating extends to the proffering of corrective action plans
as well.
In the case of the corrective action measures submitted by UHS
Hartgrove officials to CMS – as well as similar assurances made
by hospital leadership during a recent meeting with UIC reviewers
– the findings of the current report suggest that the outcomes of
such plans will likely be as successful as the previous efforts to
remediate deficiencies at this hospital: which is to say, not at all.

Implications and recommendations for DCFS.
Regrettably, since the performance record of UHS Hartgrove
officials seems to include deceptive practices, intimidation of any
staff who might wish to provide information to the UIC reviewers,
and misrepresentation of facts regarding the care of DCFS wards,
the Department can have little basis for confidence in continuing
a working relationship with this hospital at the present time.
With regard to specific recommendations that the Department
should consider in the meantime, the UIC reviewers would urge
that DCFS initiate a longer-term assessment of the mental health
services its wards require, particularly with a focus on the nature
of the settings in which that treatment will occur.
•

First, the problem of understaffing of psychiatric hospitals
did not begin with UHS Hartgrove, despite the fact that
the chaotic and often violent atmosphere of this facility
was unprecedented in the experience of the UIC team.
Nevertheless, since the current report is now the fourth
time that the Department has been confronted by the
problem of psychiatric hospital understaffing, it seems
appropriate to begin to develop a public policy response
to address this clinical impediment to quality of care.
As for any future discussions with UHS Hartgrove about
lifting the intake hold, DCFS should insist that its wards
receive care on units with a significantly higher staff ratio
than the current 1:5; whether this is achieved by (a) adding
staff or (b) subtracting beds is a discussion for another day.
Whatever the specifics of that discussion, however, it is
simply unacceptable that DCFS wards should ever again
be subjected to the unsafe conditions described in this
report, much of which are attributable to understaffing.
133

 •

Second, while there are presently no DCFS wards at UHS
Hartgrove, the issue of inadequate CPI restraint training
raises concerns about immediate jeopardy of remaining
patients or new admissions to the facility; for that reason,
the Department should provide a copy of the UIC report to
officials at the Crisis Prevention Institute so that they can
take the necessary steps to ensure fidelity to their training
model at this facility.

•

Third, UHS officials are undoubtedly going to implement
whatever corrective action measures or program changes
they deem necessary at Hartgrove, and the UIC reviewers
wish them well in those efforts; for its part, however, the
Department should not consider allowing DCFS wards
to be admitted to Hartgrove until all of the issues raised
in this report have been fully and effectively addressed.
Let us be clear on this point: the submission of a corrective
action plan does not, in itself, resolve chronic quality of care
problems; such efforts are little more than promissory notes
of good intentions to do better the next time. That is simply
not good enough, especially in light of compelling data that
promises from Universal Health Services generally cannot
be relied upon in good faith.

Finally, the UIC team reiterates its gratitude and admiration to
those current and former staff members at UHS Hartgrove who
reached out to us in an effort to share their experiences working
at this hospital. Without exception, we believe, each of them did
so out of a personal commitment to the children they were hired
to serve – and for that they also deserve the highest respect from
the Illinois Department of Children and Family Services.

134