IOEL NICO GOMEZ MARY FALLIN CHIEF EXECUTWE OFFICER COVERMDR STATE OF OKLAHOMA OKLAHOMA HEALTH CARE AUTHORITY August 2015 CERTIFIED RETURN RECEIPT REQUESTED Shadow Mountain Behavioral Health System, LLC RTC 1? 313.3. . 3 1* Attn: Michael Kistler 6262 S. Sheridan Rd. Tulsa, OK 74133 And Universal Health Services, Inc. ?11. 71.135 3133 3?136 3W5 Attn: Chief Executive Of?cer 367 South Gulph Road King of Prussia, PA 19406 Re: OHCA Response to Notice of Intent to Terminate SoonerCare Contract Provider ?and Corrective Action Plan Dear Mr. Kistler: This letter is written in response to your April 2015 letter, which was responding to the Oklahoma Health Care Authority?s (OHCA) Notice of Intent to Terminate SoonerCare Provider Contract letter sent on March 25th, 2015. After reviewing the documentation you provided, as well as conducting an onsite follow up review, 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 all federal and state laws and regulations governing entities such as Shadow Mountain. The details of the CAP are as follows: 1. OHCA considers this physical location to consist of eight (8) separate units encompassed in three (3) separate buildings. As such, staf?ng requirements are unit speci?c 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 4345 N. Lincoln Bird, Oklahoma City,0K 73105 (405)522-7300 ?mwgig; N15ng 1 An 5;;qu Oppcnun?y Employer number of staff on duty facility?wide. Shadow Mountain will ensure that it complies with O.A.C. 340:110-3-168 (required Residential Treatment Facility (PRTF) staf?ng 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. . As federal and state rules and regulations require a minimum of one (1) Registered Nurse (RN) per acute unit, a RN assigned to a speci?c acute nnit cannot cover or otherwise be counted towards the staf?ng requirement in any other unit. This also prohibits a RNwho 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 ensure that all medications will be timely administered and will be properly documented in patients? charts. Further, Shadow Mountain will also ensure that all medication errors will be prOperly recorded in the medication error report. . All incidents involving use of force, whether by employees of Shadow Mountain or other outside persons, shall immediately be reported to OHCA and any other agency required by law. Additionally, all serious injuries and instances of child abuse or neglect will be reported immediately to OHCA and the Department of Human Services (DHS). Shadow Mountain will ensure that it Speci?cally complies with O.A.C. and O.A.C. . 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 speci?cally state who should be called, the amount of time it will take to respond, and 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 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. 4345 N. Lincoln Blvd, Oklahoma City,01< 73105 - {4635224366 An Equal Opportunity Employer 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 August 19th, 2015 and will remain in place for a minimum of one (1) 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. Sincerely, Becki Burton Deputy General Counsel cc: Garth Splinter, M.D. Sylvia Lopez, MD. Melody Anthony Kelly Shropshire Kenneth Goodwin Jennifer King Becky Pasternik~Il