EOEIL NICO GOMEZ MARY FALI EN Cl ?ll" RN: t1{ STATE OF OKLAHOMA OKLAHOMA HEALTH CARE AUTHORITY March 1 2016 CERTIFIED MAIL. RETURN RECEIPT RES QUESTED Patricia A, Rogers ?31 '7qu :1qu 7035 HEEH 5733 10?h Floor. Two Leadership Square 211 N. Robinson Oklahoma City, OK 73102 Attorney for Shadow Mountain And Shadow Mountain Behavioral Health System, LLC RTC Attn: Michael Kistler El: 6262 S. Sheridan Rd. ?11 7?qu ?"1314 7035 9221] ll] Tulsa. OK 74133 And Universal Health Services Inc ?il 7 Attn: Chief Executive Of?cer I D35 367 South Gulph Road King of Prussia,PA 19406 Re: OHCA Response to Notice of Intent to Terminate SoonerCare Contract Provider Hand?and orrective ction Plan Dear Ms. Rogers, This letter is written in response to your January 15?. 2016 letter. which was responding to the Oklahoma Health Care Authority?s (LOHCA) Notice of intent to Terminate SoonerCare Provider Contract letter sent on December 2015. (As the December 30'h letter stated, the previous notice of intent to terminate letter and the response and CAP letters for Provider were incorporated by reference. and are again incorporated by reference into this 4145-5: imam Bit-Ll . iffxiihetsta 73115.? 141.3- 323731?? - .. gm) r-mn "err response.) After reviewing the documentation you provided, OHCA has decided not to proceed with a termination action at this time. Rather, OHCA has decided to place Shadow Mountain on a Corrective Action Plan (CAP) to monitor for compliance with ali federal and state laws and regulations governing entities such as Shadow Mountain. The details of the are as follows: IN) OHCA considers this physical location to consist of eight (8) separate units encompassed in three (3) separate buildings. As such, staffing requirements are unit specific and staf?ng ratios and numbers cannot be dually counted in more than one (1) unit at a time nor can the entire patient census of the facility be divided by the number of staff on duty facility?wide. There must be separate and distinct professional staff for both acute and residential units at all. times, all staff responsible for patient care must be fully dedicated to either the acute or residential unit. The staff must not take care of or supervise acute hospital patients and Residential Treatment Facility (PRTF) patients at the same time during the staff assigned hours of work. Shadow Mountain will ensure that it complies with O.A.C. 340:1 103-168 and O.A.C. 317306?9524 (required PRITF staffing coverage ratio during hours of sleep is one (1) tech for eight (8) patients and during waking hours is one 1.) tech for six (6) patients for every unit that comprises this location. Additionally, there must be 24 hour nursing care supervised by a Registered Nurse (RN). Further, Shadow Mountain will. ensure that it complies with O.A.C. 317306-9524 (required specialized PRTF staffing coverage ratio during hours of sleep is (1) tech for six (6) patients and during waking hours is one (1) tech for three (3) patients for every unit that comprises a specialized PRTF at this location. Additionally, there must be 24 hour nursing care supervised by a RN. As federal and state rules and regulations require a minimum. of one (1) Registered Nurse (RN) per acute unit, a RN assigned to a specific acute unit cannot cover or otherwise be counted towards the staffing requirement in any other unit. This also prohibits a RN who is assigned to a specific acute unit from being utilized in any other way including as an admissions nurse, house supervisor, or for seclusion and restraint purposes. Shadow Mountain will ensure that each acute unit has a least one (1) RN dedicated to it and that the RN will not be utilized in any other manner while dedicated to the speci?c acute unit. Shadow Mountain will develop an internal policy and instructions to staff on the proper process to follow for a seclusion and restraint incident. The policy should specifically state who should be called, the amount of time it will take to respond, and 4343 City,QK rains . ties} Bazaars - 32.33 Elgar-n5 E's'ttpg?eyer comply with federal and state law regarding the use of seclusion and restraint. Shadow Mountain will ensure that the policy is distributed to staff and that the contact information is visibly posted for staff to easily access. Additionally, Shadow Mountain will provide immediate and unhindered access to the facility to OHCA employees who are onsite, whether previously announced or not, for compliance reviews with this CAP and any and all state and federal laws and regulations governing such entities as Shadow Mountain. OHCA understands Shadow Mountain?s concerns regarding having a staff member to escort OHCA staff during the onsite review; however the utilization of an escort should not be used to delay or stall OHCA from immediate and unhindered access to the facility. OHCA will conduct periodic onsite reviews and is not limited in the number of reviews to be conducted nor is OHCA limited in the time or scope of such reviews, as the primary purpose is to monitor for Shadow Mountain?s compliance. When a provider enters into a contract with the OHCA, the. provider agrees to abide by all terms of the contract. The contract states that providers agree to comply with all applicable laws, including but not limited to, state laws, federal laws, and federal and state Medicaid statutes and regulations. OHCA believes that you have previously failed to abide by the terms of your contract and have failed to adhere to the regulations, policy, and laws governing entities such as Shadow Mountain. The OHCA has decided to impose a CAP upon Shadow Mountain rather than proceed with termination of the contract at this time. This CAP is effective today, March ll?h, 201.6, and will remain in place for a minimum of one year and is subject to renewal at the discretion of OHCA. However, this CAP serves as further notice to Shadow Mountain that any further policy or contractual violations will result in further action up to and including termination of the contract. CC: Sincerely, Becki Burton Deputy General Counsel Becky Pasternik?Ikard Sylvia Lopez Melody Anthony Kelly Shropshire Kenneth Goodwin Jennifer King Traylor Rains, ODMHSAS Provider Enrollment 4343 N. Lincuit?: Blvd? CEani?ic-nta 'City, 593395 {435'} $22-$3iiti mew :th finial? {fitniortnurttr impinge.?