. 4 2015 SHAW MOUNTAIN OHCA LEGAL DMSION BEHAVIORAL HEALTH SYSTEM April 5, 2015 Ms. Becki Burton Deputy General Counsel Oklahoma Heatth Care Authority PO Drawer 18497 Oklahoma City, OK 73154-0497 Re: Notice of Intent to terminate Sooner Care Provider Contract Dear Ms. Burton: Shadow Mountain Behavioral Health System requests a review of the decision by OHCA to terminate Sooner Care Contract - Below are the responses why this contract should not be terminated. 1. On the 11:00 pm - 7:00 am shift, there were (2) Registered Nurses and one Licensed Practical Nurse-- who was listed as a RNwon duty for seven separate units encompassed in three separate buildings. The two RN's were assigned to the Acute Adoiescent and Acute Children's units. There was not a RN dedicated to the Adult Acute unit, or were there RNs to provide adequate coverage for the four residential level of care units. Shadow Mountain's response: OAC 340:110-3-168 and CFR state the staffing pattern must insure the availability of a registered professional nurse 24 hours each day and that there must be adequate numbers of registered nurses, iicensed practical nurses, and mental health workers to provide the nursing care necessary under each patient?s active treatment program. 1. Shadow Mountain wili assure that a RN is available 24 hours a day to provide direct care to patients. 2. The CNO/designee will monitor daily to assure RN avaiiabie to provide direct care to patients by checking daily assignment sheets and reporting data into Pi committee 2. Per OAC the required Residential Treatment Facility (PRTF) staf?ng coverage ration during hours of sleep is one (1) tech for eight (8)patients and during waking hours is one 1) tech for six (6) patients The facility staf?ng sheets for the 11:0 pm - 7:00am shift on the PRTF units documented a ratio of 10:1. However 10:1 is out of compliance with required staf?ng level during hours of sleep. It was observed during the review that the PRTF units for this contract location were staffed at a ratio of 15:1 and 22:1. These ratios exceed the maximum ratio and are a violation of poiicy and the terms of the contract. Shadow Mountain's response: The facility staffs to meet the staf?ng ratios. A census of 122 patients with 15 staff on the schedule was a ratio of 1:8 for the 11-7 shift. Previous IOC's and Service Quality Reviews of the Sheridan campus RTC programs have not indicated a problem in compliance with staffing. 1. As of 4-13-15 an additional FTE has been added to the 11-7 shift providing direct care coverage and to meet change in pending OAC recommendations. Staf?ng will be reviewed each morning by senior management team to assure compliance. Staf?ng wiil be reviewed two hours prior to each shift by CNO and/or house supervisor. AOC administrator, which is comprised of senior management, is on call 24 hours a day if additional heip or assistance is needed. 4. These changes will be effective Aprii 13, 2015. 3. Of the staff interviewed, 42 of 56 identified lack of tech coverage as an issue. Further 38 of 56 staff interviewed identi?ed iack of nursing coverage as an issue. Areas staff identi?ed as being affected by insuf?cient staff coverage inciude: patient safety; staff safety; no experienced or core staff; decreased coverage during breaks; responses to "code greens" decreases coverage and sometimes no one responds at ail? no staff adjustments to cover 1:1 ratios' and medication errors. According to some staff, requests to increase staf?ng to adjust for acuity were discouraged by administration. Shadow Mountain response: Anonymous employee engagement surveys are compieted annuaiiy. The most recent employee survey dated March 10, 2015, indicated positive outcomes in the following areas: 1) that staff felt that staff members support one another, learn from mistakes and make positive changes as a unit, 2) are encouraged to report mistakes, 3) that supervisors take empioyee suggestions for improving patient safety seriously, 4) that there is a process to freely raise concerns about patient safety, 5) that staff discuss errors on the unit, and ways to prevent errors from happening again, 6) that important patient care information is passed on during shift changes, and 7) that management is focused on patient safety. Patient satisfaction surveys indicated a 4.63 mean out of a 5 point scale of satisfaction with the care they received while a patient at Shadow Mountain. The patient satisfaction survey scores have continued to increase over the past year. 1. All direct care empioyees go through required training, orientation and receive competency evaluations of their performance. Shadowing of new employees is mentored by experienced team members and staff. 2. Code Green teams are assigned at the beginning of each shift on each unit and will be monitored weekly through the House Supervisor and CNO to ensure response. 3. Senior Management members have been meeting individualiy with ail direct care staff to focus on Service Exceiience and how to ciearly communicate ali concerns. This will continue to improve management and direct care staff relationships. 4. Shadow Mountain Bi-l will add anonymous suggestion boxes by Friday, April 17, for employees to give anonymous recommendations for improvement. These suggestions wiil be reviewed during weekly leadership meetings. An order for 1:1 staf?ng can only be given by a physician and they are followed as given. 1. If a 1:1 is ordered, an additional staff is provided for the 1:1. There is a physician on cali 24 hours a day so decisions as to the need for 1:1 coverage or adjustment for acuity levels can be made at any time. 4. Some 11:00 pm - 7:00 am shift nurses were observed administering the day shifts eariy morning medications. However, due to the lack of nursing coverage some patients received their medications weli over an hour iate. When the team left for break after 9:00 am some morning medications were still being administered. Some staff reported that medications were often administered iate; however this SHADOW Ariourniw ASSESSMENT CENTER - HEALTH CENTER . EAGLE CREEK - HOPE 6262 - TULSA, 74133 - was not re?ected on the medication error report. Many staff, including tech staff, stated that they needed to make sure the nurses were administering medication to the patients. Shadow Mountain response: It is the practice for the overnight nurses or Medication Technicians to set up and administer early morning medications on RTC units. Shadow Mountain has a poiicy for medication and administration and steps to foliow if assistance is needed with medication administration. Without speci?c patient names, it is dif?cult to investigate. Nursing staff are encouraged and trained on how to complete a medication error variance as well as contact the CNO with any questions or problems that arise that could result in medications not being dispensed as ordered. 1. Nurses be retrained on 4-14-15 on Shadow Mountain?s medication administration policy and how to complete a medication error variance. 2. Random audits will be conducted on medication administration protocoi compiiance. 3. All medication events are reviewed by CNO and the pharmacist for trending/corrective actions. 5. Some staff reported there was an incident they termed a riot, although they stated administration threatened to fire anyone they heard calling it a riot. This incident reportedly inciuded a patient being injured, a staff member sustaining an ankle fracture, and a staff member being stabbed in the forehead with a pencii. None of these occurrences were documented on the critical incidents provided to the Service Quaiity Review (SQR) team. The police reportedly used pepper spray on the patients and some staff were inadvertently sprayed with pepper spray. The Chief Operating Of?cer indicated verbaliy that they did not do an incident report about the use of pepper spray on their patients because they were not the ones to use the spray. Staff reported the incident was the resuit of a combination of inadequate staff coverage and a tack of experience staff on the unit. Per OAC serious injuries are required to be reported to OHCA, which was not done. Shadow Mountain response: On 2-5-15 at 1:15 pm, a iicensed clinician confronted a unit of patients about their behavior. Some patients stole her badge. The nurse executive called the police. The poiice pepper spray. The CEO, Medicai Director, doctors and additional staff responded to the code. Patients were separated into small groups and the unit was returned to calm. The injuries that are indicated in this letter were not results of physicai attacks. The patient?s injury occurred when the patient scaled two fences surrounding Shadow Mountain and went AWOL. The patient was returned to Shadow Mountain with self?in?icted cuts on his forearms. The patient was seen by the nurse practitioner, the medicai director and referred out for further medical treatment. This injury was reported to the DHS Hotline on 2-5-15 at 5:38 pm and the Of?ce of Client Advocacy (OCA) investigated and screened out the referral on 2~6~15 at 10:24 am. The staff member was injured when he was running during the AWOL incident and stepped in a hole. OAC requires serious injuries to be reported to OHCA but these injuries were not considered serious. Shadow Mountain followed procedure and there were no attempts to hide or cover up this event. It is unknown as to what the report of a staff member being stabbed in the forehead with a pencil is referring to as this letter is the ?rst time any information like this has been known. There were not any staff injuries of this type during this incident. 1. All incidents are reported on an incident report, reviewed by the Risk Manager and reported in a daily morning leadership meeting. Intense analysis/root cause anaiysis is completed on all high risk incidents. 2. Ail patients' injuries are reported to OCA and are investigated. 6. Some staff reported ailegation of sexual contact between patients and sexual misconduct between a staff member and some patients that were not properly reported to OHCA. These had not previousiy been reported to OHCA. Per OAC instances of child abuse or neglect are to be reported both to OHCA and DHS. SHADOW Moummrv irlOSi?iTAL CENTER. - itwransrot Bianwwormt CENFER EAGLE CREEK - 6262. - . 918~492w8200/iw800~821~6993 Shadow Mountain response: The only allegation of sexual contact between a staff member and patients was reported to OCA on 10-23-14 and to the Tulsa Police Department. A finding of the OCA investigation is still pending. The Tulsa Police investigated the allegations and ruled that the allegations were untrue. This is the only allegation of sexual contact between a staff member and patients known to Shadow Mountain leadership. 1. All allegations of sexual contact are investigated and reported to OCA. 2. All incidents are reported on an incident report, reviewed by the Risk Manager and reported in a daily morning leadership meeting. Intense analysis/root cause analysis is completed on all con?rmed high risk incidents. 7. Additionally, Shadow Mountain has various contract locations, including the location that is the subject of this letter, on Corrective Action Plans (CAPS) with OHCA. In fact, this contract location, as well as several others, has been on a CAP for at least the past two years for several of the issues listed in this letter. More speci?cally, inadequate staf?ng ratios continue to be an area of concern. The point of a CAP is for a contracted provider to address and remedy de?ciencies, areas of concern, and any other contractual non-compliance that OHCA has investigated and brought to the attention of the provider. Shadow Mountain does not appear to be complying with the terms of the CAPS entered into with OHCA. Shadow Mountain response: 1. Shadow Mountain takes all regulatory requirements and ?ndings seriously and implements actions for all ?ndings to ensure compliance. 8. Lastly, it appears that you have not kept your corporate ownership information up-to?date with OHCA, as required. While OHCA has received updated ownership information for several of Shadow Mountain?s numerous contracts, not all of the contracts have been properly updated to reflect the current corporate ownership information. Your corporate ownership information on ?le with OHCA for this particular contract is still listed as Solutions, inc, 6640 Carothers Parkway, Ste. 500, Franklin, TN 37067. It is a provider?s responsibility to make sure all information is current and correct for every entity and contract location. Shadow Mountain response: 1. As of this date, Shadow Mountain has assured that corporate ownership is up to date. Shadow Mountain is committed to providing quality behavioral healthcare to the residents of Oklahoma. I appreciate your consideration of the information provided and I am available if you have any additional questions. Sincerely, Michael Kistler Chief Executive Officer MOUMAEN HosriTAL CENTER REVERSIDE Berries-taint CENTER . EAGLE CREEK - l?iOPli-i 6262. SounwiSi-isnimiv - 74133 - 9l8v492ws200/l~800~821~6993