- Review of Chicago Lakeshore Hospital Prepared for the Mental Health Policy Program Department of University of Illinois at Chicago Illinois Department of Children and Family Services Table of Contents Executive Summary 1 I. Scope Methodology of the UIC Review ll. Summary of Findings Patient Safety Health Issues Treatment Services Treatment/Discharge Planning Hospital and Unit Management Issues Corporate-level Quality of Care Issues Selected Case Reviews of DCFS Wards 25 Case 1: MG Case 2: PC - Case 3: DB Case 4: JD - Case 5: AG Conclusions Recommendations 40 List of Attachments 44 Centers for Medicare Medicaid Services: Selected reports on Aurora-operated hospitals in Illinois, California and Michigan United States Attorney's Office for the Eastern District of Michigan: 2005 Annual Report Federal Court complaint: United States of America ex rel. Clark v. Aurora Healthcare Office of the Attorney General of California regarding: Medical Board of California; Case No. 11-2007-188043. California Board of Registered Nursing; Case N0.2010- 300 Case No. 2010-299 Selected news media reports: Los Angeles Times, Detroit Metro Times and Chicago Tribune Executive Summary I. Scope and Methodology of the UIC Review. The UIC Mental Health Policy Program was asked to conduct a quality of care review of Chicago Lakeshore Hospital on behalf ofthe Illinois Department of Children and Family Sen/ices.' The UIC team initiated its review process by meeting with hospital administrators on June 3, 2010; thereafter, the team conducted a period of random observation of staff-patient interaction on the units, covering all shifts, lasting through the end of July; follow-up visits continued through October? Inten/iews were conducted with hospital administrators at various levels, including the CEO, medical director and other senior managers as well as direct-care unit nursing staff. As part of its standard protocol, the team examined data on health and safety-related issues for approximately a 24-month period preceding the start of the on-site review; the team also inspected the hospital's physical plant, including patient units, cafeteria/food storage, kitchen and other areas of the facility. A database list of all admissions of DCFS wards from January 2008 through June 2010 was generated, from which a sample of wards - each of whom had experienced multiple hospitalizations to CLH - was selected for closer evaluation. 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 team members also obsen/ed treatment review meetings for seven of the wards who were currently hospitalized. Approximately 9,000 pages of documents were reviewed, including: histories of wards; treatment and discharge plans; minutes of the medical executive staff committee and risk management committee meetings; policy and procedure guidelines; unusual incident reports; survey reports by state and federal agencies; news media reports, federal court documents; and other data indicative ofthe quality of care being provided to DCFS wards at this facility. 1 The review team was headed by Dr. Ronald Davidson, director ofthe UIC Mental Health Policy Program, and included: Petty, Forrest Brown, Dr. Barbara Fish; and Christina Kraemer, LCSW. Dr. Michael Naylor provided consultation and clinical data reviews regarding certain medical and issues, and Dr. Christine Davidson provided database analysis on hospitalization records of DCFS wards. 2 The UIC team appreciated the cooperation of Chicago Lakeshore ofhcials and staff during the review process. Dr. Davidson met with the CEO and other administrators on several occasions to discuss issues that arose during the review. Dr. Davidson and Dr. Naylor later held an exit interview with CLH ofticials on December 20 to review the UIC report when it was still in draft form; the inal UIC report therefore considered certain feedback and critical responses from CLH representatives as a result of that meeting. Common element in each sexual assault a failure by Aurora/CLH officials to ensure adequate staffing and monitoring of hospital units. ll. Summary of Endings. While this report will assess clinical issues pertaining to the care of certain individual wards, special attention will also be focused on broader systemic data regarding quality of care performance; specifically: staffing/monitoring of hospital units; patient safety and health; treatment and discharge planning issues; hospital management; and corporate-level issues that may impact the quality of care at Chicago Lakeshore Hospital. Staffing and monitoring of hospital units. The UIC reviewers identified a number of concerns related to inconsistent or inadequate staffing and monitoring of the hospital units, some of which appear to have compromised patient safety and led to serious incidents of harm: Records indicate four cases - two in 2008, and one each in 2009 and 2010 -in which hospital officials reported sexual incidents by patients on the child and adolescent units? Further, sexual acting-out incidents at CLH have included cases where one or more of the youths were on some level of staff observation or special precaution, indicating a clear breakdown in monitoring procedures, 0 In one ofthe 2008 incidents, a 15-year-old girl told staff she had been engaging in sexual activity with a male patient in her bedroom; staff subsequently discovered both patients in the girl's bathroom, noting that she was unclothed from the waist down. 0 In the 2009 incident, four boys were able to crawl past the unit nursing station, without being detected by staff, to a bedroom where two female patients were sleeping. One ofthe girls reportedly told police that a male patient followed her into the bathroom, grabbed her by the hair and forcibly raped her. Finally, in the 2010 incident - which occurred during the period that the UIC team was still conducting its review at CLH - an adolescent male was able to go into the bedroom of another boy, undetected by unit staff, where the two youths reportedly engaged in oral and anal sex. In sum, the common element among each of these alleged sexual assault cases appears to be the failure by Aurora/CLH officials to ensure adequate stafhng/monitoring of the hospital units, an issue that is examined below in the section on corporate responsibility. 3 A case involving the alleged rape of an 11-year-old boy at CLH in 2008 is discussed below on page 6; these and other incidents were also detailed in a Chicago Tribune investigative report on September 21, 2010. UIC reviewers routinely observed instances at CLH where a single staff member was monitoring as many as 15-22 youths in the unit dayroom areas. These obsen/ations by the UIC team members were echoed in written comments from CLH staff themselves in a hospital employee survey (discussed below on pages 14-15). On occasions when two staff members were obsen/ed working the dayroom, typically one staff would be sitting at the table doing charting or papen/vork but not directly monitoring patients; at other times both staff members were observed seated at the table talking with each other but not directly attending to patients' behaviors. On several occasions, UIC reviewers observed patients acting in provocative (and, in one instance, menacing) ways toward other patients, exiting their rooms (where they had been temporarily restricted) or engaging in behaviors that went undetected or unaddressed by staff who were assigned to supervision/monitoring duties. Similarly, during a June 15 visit on the adolescent unit, UIC reviewers observed a youth - who had been placed on line-of-sight precautions after injuring himself- sitting in the hall with no staff members in sight for some time. Later that same day, another youth - who was not allowed to participate in activities because of his levels restriction - was observed standing in the doonivay of his bedroom and provoking a second patient who was in the dayroom area; unit staff neither noticed or intervened in this situation. In another instance in June, UIC reviewers observed the AT conducting a group with 12 patients in the dayroom of the adolescent unit; a staff member sat at a desk near the group but was soundly sleeping; this situation was noticed by several ofthe patients in the group, who then began pointing at the sleeping staff member and giggling. On a positive note, the UIC reviewers obsen/ed a number of physical restraint episodes involving both DCFS wards and non-wards, all of which appeared to be conducted safely and professionally. Of special interest, hospital data on restraint-related patient and/or staff injuries were relatively low, indicating effective training in this area." A Specifically absent from the observed restraint episodes - as well as from the records of restraint usage since 2008 - were any indicators that hospital staff utilized restraints inappropriately or punitively; or that restraint usage was driven by a loss of control on the inpatient units (such as a chronic pattern of aggressive outbursts, threats of violence or an unsafe environ- ment), troubling features that have recently been shown to plague some Illinois facilities sewing DCFS wards. CLH units continue to present unacceptable risks at times because of lax or inconsistent supen/ision by staff. Patient safety and health issues. The UIC team identihed several critical issues relating to patient safety and health at CLH - chief among them what appears to be a recurring question of a supen/ision failure on the inpatient units, a factor that directly contributed to each of the sexual incidents summarized in the current report. At the same time, the UIC reviewers were impressed by efforts of certain CLH professional staff- hospital nursing leadership, in particular -to address structural weaknesses in unit milieu management and facility-wide administration that impaired the ability of staff to ensure patient safety. However, as commendable as such efforts may have been - and the UIC team felt there was a genuine acknowledgement on the part of nursing leadership about problems with milieu management and patient safety issues - the fact remains that the CLH units continue to present unacceptable risks at times because of lax or inconsistent supervision. ln fact, the corrective action plan submitted by CLH to DCFS -following a reported sexual assault incident in June 2009 - is of interest as much for what it does not say as it is for its evaluation ofa milieu failure episode: For the most part, the corrective action plan fixes blame for the incident - in which an adolescent male patient was alleged to have sexually assaulted a female patient in her bedroom - on the unit's direct-care staff, who were found to have not conducted 15-minute room-checks as required by hospital procedures. According to a summary ofthe incident in the corrective action document, certain unit staff were suspended and later terminated, along with several charge nurses and a nursing supervisor, following the internal review of the incident. 0 The corrective action plan enumerates a range of policy and procedure changes that CLH oficials considered necessary to implement in response to this incident: educating nurses/supervisors about strategies for monitoring/education of staff; development of an 11-7 procedure to ensure patient identification and safety while conducting rounds and monitoring patients; two signatures required between shifts when handing off precautions after making rounds. Curiously, the corrective action plan adds a comment that CLH officials "reiterated [during a unit meeting] the importance of adequate monitoring of hallways on evenings, but especially on 11-7, by placing at least one staff in front of the nurses' station." [See Diagram 1 on the following page.] 5- .P .. iff'fig .A vin wr tw., 1 1" ,ut Failure to routinely post a staff member in front of the central nursing station leaves three unit hallways inadequately monitored1'-Nursin S-tation I Diagram Floor plan of child and adolescent unit. iL 0 Also of interest, the corrective action plan indicated that hospital officials would "add a staff to the unit on 11-7 for increased monitoring." 5 What is most striking about the above corrective action plan, however, is that CLH officials appear to have offered similar proposals following other incidents - both before and after this July 2009 sexual incident- suggesting that implementing and/or sustaining such interventions is often unreliable at best, especially when recycling previously ineffective policies: First, a September 2008 survey conducted by the illinois Department of Public Health found that hospital officials had "faiIed to protect and ensure the safety of patients" - including a sexual assault case in which two 11-year-old DCFS wards allegedly sodomized another 11-year-old child in a bathroom on the children's units While this IDPH report was dated about 10 months before the July 2009 corrective action plan submitted to DCFS, CLH officials stated in their IDPH corrective action reply that the hospital would introduce "a new to monitor compliance and documentation of 15-minute obsen/ations at the end of each shift before hand-off to the next shift," This is followed by: a comment that one or more of the various program/nursing supervisors will "sign-oft" on these 15-minute obsen/ation checklists at the end of each shift; assurances that "mandatory staff training [on the new hospital procedures] will begin immediately/'; and indication that "progressive disciplinary action for non-compliance. will follow. 0 Second, another sexual incident at CLH in October 2009 - three months after the corrective action plan submitted to DCFS - led hospital ofncials to again offer corrective action measures that appeared identical to what DCFS had been assured were already implemented: that is, monitoring of the hallways by having a unit staff member detailed to sit in front of the central nursing station on all shifts to ensure that sexual incidents did not occur. UIC reviewers inspected stafhng records and verified that hospital officials added one additional staff on the 11-7 shift. Under the circumstances, and especially in light ofthe problems inherent in monitoring the physical layout of the CLH units, this was an appropriate short-term corrective action step, although staff levels alone cannot ensure patient safety in hospital settings - especially if general supervision is inconsistent or rules are poorly enforced. 5 6 Cook County Circuit Court records show that the mother of the child victim in this incident later filed a lawsuit against Aurora alleging various acts of negligence; the 2009 case was ultimately settled with a monetary award to the victim [see Cook County Circuit Court: Case Number 2009-L-0056861 ,~-aww A recurring problem of ineffective clinical and administrative oversight clearly undermined the basic responsibility of hospital officials to monitor and ensure patient safety. ln other words, after four sexual incidents involving patients over a 13-month period, hospital officials promised to address what was clearly an ongoing problem of supervision failure by introducing essentially the same corrective actions each time - as if simply implementing previously failed, ineffectual or poorly enforced policies would ensure patient safety. At issue here, it should be emphasized, is not simply a failure by staff members on a particular shift to adequately monitor the unit - to their credit, CLH officials readily acknowledged that various breakdowns of established hospital procedures had occurred in these cases - but rather a recurring problem of ineffective clinical/administrative oversight and inconsistent supervision; in this case, poor programmatic supervision of staff clearly undermined the basic responsibility of hospital officials to monitor and ensure patient safety.7 Treatment services treatmentldischarge planning. During the course of examining patient charts and hospital records, the review team identified a number of quality of care concerns related to treatment services as well as treatment and discharge planning for DCFS wards: Medication management issues. Special concerns were raised about emergency medication usage in certain cases, as indicated in a section below in regard to patients identified by their initials: MG and JD. 0 Additionally, UIC reviewers identihed numerous cases of medication errors or medication issues affecting DCFS wards at CLH, including: medication non-compliance not addressed in treatment plans, missed doses, incorrect doses; and inadequate or poor MAR documentation. In one case, a DCFS ward received too low a dose of an medication (60 mg total instead of 160 mg), despite the fact that the proper dosage was listed on her intake information at admission; she was also placed on an SSRI that had been discontinued at another hospital three weeks earlier. The patient's behavior on the CLH unit soon escalated - she reportedly punched a staff member in the face - before the correct medications and correct dosages were later identified during a treatment team meeting (which involved staff from her community residential program on a telephone conference call with the CLH team). The UIC team examined available data -including surveys by state and federal law enforcement and healthcare authorities, and news media reports - regarding other facilities operated by the Aurora corporation in California and Michigan, some of which are summarized and attached below; taken as a whole, these data suggest a consistent pattern of recurring risks to patient safety because of supervision failures in certain Aurora-owned facilities. 7 Similar issues arose with another DCFS ward, PC, whose history of enuresis and encopresis was indicated in his intake information; PC's mother also suggested that CLH staff contact his pediatrician regarding his regular meds. CLH records show that PC subsequently did not receive his regular medication (docusate sodium) for encopresis, nor another medication (DDVAP) for enuresis. Reviewers noted that PC later apparently defecated in a hallway and in the dayroom on the children's unit, and multiple incidences of bedwetting at night were reported. Another ward, JD, was given an emergency medication even after telling nursing staff that he was allergic to that medication (despite the fact that his allergy was clearly listed in his medical chart as well as on the MAR). Reviewers also noted that CLH nursing documentation often lacked indications regarding injection rotation sites arms, thigh, buttocks, etc.) when patients were given IM emergency medications, making it difficult for hospital QA staff or nursing supervisors/managers to track this quality of care indicator." 0 Finally, the UIC team examined a 2008 survey of CLH by the Illinois Department of Public Health - conducted on behalf ofthe federal Centers for Medicare Medicaid Sen/ices - certain findings of which were consistent with observations on medication issues noted above during the 2010 uic review." 8 See advisory on IM injection issues in: 503. an/cle. 9 The CMS survey from December 2008 cited CLH officials for "failure to ensure medications were administered in accordance with physicians' orders" [42 CFR CMS also cited CLH officials for failure to ensure that abuse/losses of controlled substances were properly reported in accordance with Federal and State laws [42 CFR 482. This finding refers to the apparent theft of Norco - an opiate painkiller and DEA-controlled narcotic -from the pharmacy and the substitution of "replica" tablets, Tylenol, presumably by the persons who committed the theft. There was no indication in the CMS report. unfortunately, as to whether patients had received the replica tablets before the substitution was discovered. According to the CMS report, CLH officials inexplicably failed to notify either the Drug Enforcement Agency or the Chicago Police Department until after the CMS surveyors had discovered a year-old internal report documenting the theft of the narcotic. Treatment and discharge planning issues. Evaluation of both current and closed cases of DCFS wards revealed at best an inconsistent approach to treatment/discharge planning, as evidenced in a number ofthe clinical quality of care problems in the individual case reviews below. In general, these problem areas included: 1. Treatment plans inadequately addressed identified clinical issues of patients; or 2. Treatment plans failed to identify clinical issues that should have been a focus of inpatient treatment; 3. Patient non-compliance issues regarding medications were not effectively addressed in some cases; 4. Progress notes and treatment plan reviews were sometimes non-specific; 5. Treatment team planning regarding certain DCFS wards with excessive hospital length-of-stay issues were not appropriately managed; 6, Discharge/aftercare planning were inadequate for certain DCFS wards with histories of placement instability and/or hospital recidivism. UlC's observations on treatment plan documentation were mirrored in findings ofthe Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which conducted a survey of CLH last April 12-14, approximately six weeks before UIC initiated its review. JCAHO's report later indicated a number of compliance issues regarding hospital accreditation standards. While most of these issues involved relatively minor problems, the JCAHO surveyors also identified quality indicators consistent with the types of clinical deficits obsen/ed by the UIC reviewers."' CLH officials took issue inthe December 20 meeting with the draft UIC reports described the JCAHO findings (as detailed below in footnote 11). In later responding to the UIC analysis, CLH argued that the "requirements for improvement" identified by the JCAHO surveyors - referring specifically to suicide risk assessments - were "misleading and not indicative that suicide risk assessment(s) [were] absent from the chart(s). CLH officials reframed the issue as simply a technical difference between how hospital had been conducting/documenting suicide risk assessments versus the "preference ofthe JC sun/eyor [for] a 'stand-alone' assessment." 10 It seems unlikely that the "preference" of a sun/eyor would find its way into formal JCAHO requirements for improvement, especially since the CLH corrective action plan subsequently complied with the requirement; footnote 11 therefore was not changed after the objection by CLH ofhcials. Among the clinical quality of care issues identified by JCAHO at CLH, certain indicators underscored apparent procedural weaknesses that might pose risks to patient safety and undermine effective treatment, as detailed in the footnote below. 11 Summary of selected JCAHO findings: ln three cases - each involving patients on the child and adolescent units who had been admitted following suicidal ideation or, in one instance, an actual suicide attempt- JCAHO surveyors noted that CLH clinicians had failed to conduct required suicide risk assess- ments to "identify specidc patient characteristics and environmental features that may increase or decrease the risk of suicide." ln one case on the child and adolescent unit, JCAHO sun/eyors noted that "a child had been admitted with the identlhed problems of 'suicide attempt' and inappropriate sexual behavior as well as potential prob- lems with thought processing." A second youth had been admitted to CLH with identified multiple risk factors, including Disorder and aggressive behavior, while the third child had a history of self-harm and self-harm threats as well as _alcohol and other drug use. Despite these identified risk factors, JCAHO surveyors found that these children received no suicide risk assessment at CLH that would have "identihed either potentiatlng or protective factors," indicating that there was "no objective process for the detemtinatlon of risk," At the same time, the JCAHO surveyors also identified problems in medical record documentation related to federal standards, specifi- cally as defined in 42 CFR ?482_24(c) (regarding justification for admission and continued hospitalization, information supporting the diagnosis, and a description of the patients progresslresponse to medication/sen/ices). As did the UIC reviewers, JCAHO surveyors found signiicant problems with progress notes and other areas of medical documen- tation that are the primary means of evaluating what is occurring in treatment and determining whether patients are receiving quality care. In April, for example, the JCAHO surveyors noted patient charts that were "incomplete and had omissions of whole sections of information, and/or blank spaces for required information." While the UIC team did not conduct a review of the outpatient clinical services site at CLH, the current report includes some of the JCAHO surveyors' findings because that program operates under the same management structure as the hospital itself- and, according to the JCAHO report, appears to share similar management problems with regard to basic procedures and ineffective clinical oversight: [Footnote 11 is continued below_] Returning to the 2008 CMS survey conducted by IDPH, cited earlier, it is useful to note similar findings in this area by another set of independent experts, which suggests a longstanding pattern of clinical deiciencies that hospital administrators and medical leadership at CLH appear to have difficulty effectively and consistently remediating 12 [Continuation of footnote 1 ln one case, a 14-year-old girl "admitted post acute inpatient hospi- talization with a diagnosis of Major Depressive Affective Disorder Recurrent Episode a Suicide Assessment Risk [had not been administered] either during the recent inpatient stay or since admis- sion to the Outpatient Day Service. No protective or potentiating factors were determined, no environmental factors detailed, thus no objective assessment of either the presence of or level of risk was conducted which would inform clinical services and assist in planning aftercare" [emphasis addedl, JCAHO surveyors cited two other outpatient cases - one a 14-year- old girl with a diagnosis of Depressive Disorder, the other a 17-year- old girl with a diagnosis of Major Depressive Disorder- where CLH clinical staff had failed to administer suicide risk assessments. Similar deiciencies were found in treatment plans, initial evalua- tions and other clinical documentation - as the UIC reviewers also discovered - all of which (as the 2010 JCAHO surveyors concluded) "poses problems for determination of care, treatment and sen/ices," 12 Specifically, the 2008 CMS report indicated detlcits in some very basic areas having to do with patient care and treatment planning: such as the criteria for documenting evaluations [42 CFR and the monitoring/evaluation of quality and appropriateness of treatment services provided by medical staff, including screening neurological exam- inations [42 CFR The CLH medical director acknowledged these and other identified deiciencies, and the 2008 CMS report contains corrective measures that hospital officials and the medical director indicated would be implemented. For example, the CMS report identified certain deficits regarding discharge and aftercare issues - including the content, accuracy, quality and time- liness of patients' treatment plans, evaluations and other medical records [42 CFR - an ongoing concern identilied by the UIC team as well during the current review. With reference to the discharge component of patients' medical records, CLH's health information manager acknowledged that the hospital had 127 records incomplete beyond 30 days of discharge at the time of 2008 survey, and CLH officials submitted a corrective action measure indicating that physicians who failed to comply with the 30-day threshold would be subject to "the disciplinary process as per the bylaws and rules/regulations of the medical staff." While such technical medical records documentation issues are important, the UIC team is more concerned about the actual quality and usefulness of treatment and discharge planning for DCFS wards at the current UIC review identified a number of case examples involving treatment/discharge planning problems, and DCFS should continue to monitor quality of care in this critical performance indicator as a high-priority issue at CLH. Hospital and unit management issues. While the UIC review identined a range of problem involving quality of care and clinical performance issues, it should also be noted that the hospitals management structure evidences certain that tend to mitigate the daily impact of these problems to some degree [as indicated above on page Specifically, the review team was impressed by the senior nursing leadership, several of whom have been at CLH for more than 20 years and who provide a critical measure of stability and experience to the hospitals operations. Similarly, the UIC team found that CLH unit-level nurse managers were generally knowledgeable, caring and skilled professionals. UlC's extended obsen/ations on the CLH units, however, found that nursing staff often had little time to actually engage with patients or provide supervision of direct-care staff in the milieu because of the excessive burden imposed by documen- tation requirements nursing assessments, restriction of rights, restraint/seclusion forms, medication consent requests MARs, progress notes, etc). Although such papenuork requirements are a normal part of any medical or hospital operations, the burden on nursing staff at CLH is compounded by the fact that there is currently no computerized record system ln place at the unit level to assist nursing managers. To their credit, CLH ofhcials identihed this issue several years ago, as seen in the minutes of the Medical Executive Committee from October 200973 "Electronic medical systems are currently being evaluated at the corporate level. A system will hopefully be selected within the next 60-90 days, with implementation [at shortly thereafter. The importance of this agenda item was further underscored by a comment (noted in the same minutes ofthe 2009 MEC meeting) attributed to the hospital CEO: "Due to necessity, CLH has requested that we be the hospital in our corporate system to have this installed. At issue here is not simply a hardware/software deficit at CLH - something that ought to have been easily remedied some time ago - but the fact that this sort of longstanding structural inefhciency has been allowed to undercut the ability of clinical staff to deliver quality care to patients."' 13 Similar notes a year earlier, in October 2008, indicate that this is both a longstanding and unresolved issue for CLH and its corporate administration. 14 See also: "Open Source Health IT in the Care Environment", Patient Safety Quality Healthcare, January/February 2011, online journal available at 66 Stafting patterns create an extremely unsafe environment and poor patient care . . .Sometimes t7nd patients left alone in the dayroom with no staff member present. 39 Comments by CLH staff members in a 2009 survey on patient safety. As indicated earlier, UIC reviewers consistently noted that unit-level nursing staff were rarely seen outside the nursing stations, meaning that direct-care milieu staff were generally unsupervised in any effective way during such periods by CLH nursing management. Such hospital environmental and practice deficiencies - including inadequate stafnng levels, ineffective patient observations and poor staff communication - are considered root causes when harm occurs to patients." Moreover, mirroring the UIC observations are a series of verbatim comments made by CLH employees about such staffing and supervision problems in the hospital:'E "Sometimes I #nd patients left alone in the dayroom with no staff member present. .. Or even if staff is in the dayroom, s/he is preoccupied with texting under the table." "Stafhng patterns create an extremely unsafe environment and poor patient care. Staff MHCs, are overworked, underpaid, under-praised and burned out. "By based on census, it means that MHCs are expected to do the work of two (or more) people, Acuity is not taken into account when stafling strictly by census, which means there are often not enough staff to handle a highly acute unit. lt is a miracle we don't have more critical incidents/sentinel events/staff injuries. "Stafhng is based on numbers and is not reflective of the acuity of the unit. Because of this, patient safety, along with the safety of staff is negatively affected. Vtdditionally, patients who are on special precautions, such as LOS [line-of-sight], do not affect the of the unit. For instance, a unit with 24 patients could very well have three LOS patients and only three counselors. lt is literally impossible to maintain LOS coverage at all times for these patients when the hospital is staffed at current levels." "The new protocol for signing rounds not only does not help make patients safe but creates anxiety for staff at all levels, based on the fear of a missed initial costing them their job. "Policies are reactionary, typically creating an additional piece of papenlvork to provide culpability for future occur- rences rather than addressing the systemic problem. SAFE Practical Applications and Approaches to Safe Practice. A Resource Document of the American Associations Committee on Patient Safety; 2009. 15 Patient Safety and Recommendations to the Board of Trustees of the American Association, APA Task Force on Patient Safety; 2003. 16 Response text comments offered by CLH staff members, as noted in a recent Survey on Patient Safety Culture (December 2009). These written staff survey comments - which are consistent in tone and content with remarks made to UIC reviewers in confidential interviews with a number of CLH unit-level staff - should not be viewed as arising simply from disgruntled employees with an axe to grind. On the contrary, the UIC team interpreted both their interview materials with staff and these verbatim commentaries from the 2009 survey at face value: that is, as forthright statements of concern by frustrated healthcare professionals who endure a daily array of unnecessary impediments to their ability to provide quality of care for patients in a safe environment." As indicated earlier, following the December 20 meeting to allow CLH officials an opportunity to review a draft of the UIC report, the hospitals CEO sent an email to Dr. Davidson and Dr. Naylor making the case for reconsideration of certain critical findings in the report. [See footnote 10.1 17 Of special interest, the CEO offered the following comment in his email with regard to the issue of harm to patients occurring as a result of ineffective monitoring of patient safety: "ln January 2010, [Aurora acquired additional property and is seeking approval to build a new inpatient building for Child and Adolescent. The new physical plant will offer an environment of care that incogorates both form and functional aspects of design. "The units will facilitate effective surveillance of milieu and atient rooms and improve safety measures by assuring that vulnerable children will have enhanced line of sight monitoring. [Emphasis added.] In effect, the CEO is implicitly acknowledging here the accuracy of one of the main Endings in the UIC report: that the CLH physical plant is itselfas much an impediment to patient safety as any failed supen/ision by staff - a chronic problem that the Aurora corporation appears to be suggesting in this email can be cured by simply initiating a real estate transaction. While the UIC team would certainly not dispute the inherent "architectural" problem of the hospitals layout- in fact, it was emphasized in Diagram 1 - the fact of poor physical plant design does not allow hospital administrators to avoid taking responsibility for inadequate supen/ision. Quite the contrary, inasmuch as this email tacitly admits that "vulnerabIe children" at CLH have suffered harm because the "environment of [lacked] "line of sight" that would allow staff to conduct effective monitoring, Aurora/CLH ofhcials now have an even greater duty to resolve this quality of care failure. In the four cases of alleged sexual assault at CLH described earlier, each instance involved an element of supervision failure that appeared to be at least compounded by poor line-of>>sight on the unit. The corrective action responses by CLH ofhcials, however, pointed mostly to various breakdowns at the level of staff supervision failure to follow established procedures, such as conducting room checks and posting a staff member in front of the nursing station so that all three hallways could be fully observed). In sum, while there was undoubtedly a procedural breakdown - one that is known to have occurred at /east four times and involved serious harm to children - it is not useful to shift the blame downward onto hospital staff, especially when it now seems clear that corporate officials were fully aware that this intractable patient safety issue signaled an organizational failure, Quality of care issues identified by state and federal authorities in California and Michigan. iles Angeles Cinws 5 "is aa.-i-1. :Ma out rm.: Inspectors found problem persisted at Pasadena hospital Government regulators documented numerous failures in patient care at Las Encinas within the last year. Corporate-level quality of care issues. As part of its standard protocol for conducting reviews of hospitals and residential facilities for DCFS, the UIC team routinely examines the relationship between local facility management and the larger corporate-level structure (when applicable) as well as the history of the corporation itself, particularly with regard to quality of care issues that may present risks to DCFS wards. The reasons for conducting such corporate-level reviews should be clear: just as DCFS has a mandated responsibility to examine the personal backgrounds of its own employees, the Department has a similar obligation to learn as much as possible about the corporations to which it entrusts its wards. Accordingly, the reviewers asked the hospital CEO for a statement outlining the facility's corporate ownership history; the following email note was provided by the CEO: 'bllurora Chicago Lakeshore Hospital, LLC, an illinois limited liability company, is owned by Signature Health- care Sen/ices, LLC, a Michigan limited liability company, which is privately held by one memben Soon Kim. The hospital was purchased in October 2001 by Signature from HCA under the name of Salem Services Company of Califomia, LLC (previous name of Signature). HCA had owned the Hospital for approximately 20 years prior to the purchase by Signature, UIC reviewers subsequently conducted an extensive search of surveys/reports by state and federal agencies regarding any AuroralSignature-owned facilities located in other states; additionally, federal court documents and news media reports regarding incidents that occurred in some of these facilities were also examined [see summaries and attachments below]. Issues identified by authorities in California. The Los Angeles Times has reported on a series of problems at Aurora/Signature-owned hospitals in Pasadena and the San Diego area between 2006-2011: Of particular concern, Aurora Las Encinas Hospital, a 118-bed facility in Pasadena, has been under continual scrutiny by state and federal authorities following reports of patient deaths and suicides, sexual assaults, poor supervision and other significant failures to ensure patient safety and quality of care. The Los Angeles limes reported one 2008 incident in which a 14-year-old girl was raped in her hospital bedroom at Las Encinas by a 16-year-old male patient; facility staff were allegedly sleeping during the assault. G6 The hospital failed to implement staff-to-patient to ensure that all patients were monitored and kept safe in a secure environment. 99 Centers for Medicare Medicaid Services 2009 report on Aurora Las Encinas. Several reports by CMS from 2008-2009 - and others from as recently as January and April 2010 - contained troubling findings about substandard care and failure to ensure patient safety at Las Encinas. Aurora officials were warned in 2008 and 2010 that their Los Angeles facility could be decertified and lose eligibility to receive federal Medicare and Medicaid funding. Speciically, a September 2009 report by CMS noted: The hospital failed to ensure that all patients were afforded their right to receive qua/ity care in a safe and secure environment. The hospital failed to implement staff-to-patient ratios.,. to ensure that all patients were monitored and kept safe in a secure environment", [and] failed to ensure that employees assigned to monitor patients on a 1:1 basis had no other responsibilities that would interfere with their assignment. The hospital failed to provide patients a safe environment [and] as a result, patients were able to inflict injuries on themselves or go AWOL thereby exposing themselves to potentially unsafe situations. The hospital failed to ensure that patients were not given the opportunity to harm themselves, or engage in behavio that had the potential to cause harm. The hospital failed to protect patients who demonstrated behavior detrimental to their well-being, to adequately reassess those patients as necessary and modify their plans of care accordingly, and to 'prevent reoccurrence of potentially harmful behaviors. 15 Among the examples cited by CMS surveyors in this 2009 report was the case ofa suicidal adult patient, admitted with command hallucinations, who was hearing voices telling him to kill himself by running out into traffic; in fact, the patient had attempted to harm himself in this way immediately prior to admission. Despite the fact that this patient had been admitted with diagnoses that included Major Depressive Disorder, suicidal ideation and a recent attempt to harm himself, the CMS surveyors noted that "there was no documented in the Suicide Assessmentn. that past/near suicide attempts or current intent were assessed [by nursing staff]." The report also noted that the patient's clinical record "did not have an interdisciplinary treat-ment plan based upon a comprehensive patient assessment. The September 2009 CMS report on Las Encinas concluded that "the failure to complete the assessment for risk for suicide for [this patient and two other patients] prohibited staff from determining the need for a care plan forthe prevention of self~injurious behavior _,wt emu. t- at ni um . imiim .tmmil. mcsum "mu min. ..-4 .W _.lm iw M. --.., ve mn 1 wi sm 1. -in "ntl Perhaps most striking, the 2009 CMS report commented that "the cumulative effect of [this] failure to ensure all patients were afforded the iight to be kept safe in the facility resulted in three patients being able to injure themselves and two patients who managed to escape from the facility." in Moreover, in each of the three cases where patients at Las Encinas were able to harm themselves, hospital ofhcials failed to ensure that clinical staff had conducted a suicide risk assessment- despite the fact that each of these patients had been admitted because of identihed suicidal behaviors or ideation." CMS surveyors raised similar quality of care issues at this Aurora facility in a December 2008 report: - The hospital failed to identify treatment interventions that provided a focus to address individual needs of 10 of 10 sample patients Hncluding a 10-year-old boy, admitted with suicidal ideation and aggressive behaviors, who had been inappropriately placed in an adolescent uniU.2? - Most of the treatment plans were preprinted, and the interventions were and failed to identify the specilic purpose or focus the intervention had for each individual patient. This dehciency results in a failure to guide staff regarding the specific treatment purpose of each intervention to achieve measurable behavioral outcomes for individual patients. 2' 19 Attention is redirected to footnote 11, above, regarding a 2010 JCAHO survey at CLH in which children with identitied risk factors for self-harm were found to have received no suicide risk assessment that would have "identilied either potentiating or protective factors," indicating that there was "no objective process for the determination of risk." 2? When questioned about this case by the CMS surveyors, Aurora ofhcials acknowledged that the facility did not have a designated program for young children; curiously, the attending told surveyors he "thought it was understood" [presumably meaning by administrators and staff] that the adolescent unit should provide age-appropriate treatment programming for this 10-year-old child separate from the older youths. This latter comment by the attending would seem to raise questions about the level of supervision in this clinical treatment setting. 21 Again, attention is redirected to footnotes 10 11, above, regarding similar findings by JCAHO, CMS and UIC reviewers with documentation and basic adequacy of medical records, evaluations, progress notes and treatment plans at CLH. As previously indicated, the issue of concern for DCFS in looking at CLH is the degree to which such similar management problems between Aurora-owned facilities suggest a corporate pattern of ineffective clinical oversight. 553Board of Registered Nurstn Finally, California healthcare authorities recently initiated enforcement actions with the California Attorney General against a and two nurses reportedly involved in the deaths of two patients at Las Encinas Hospital: The Medical Board of California filed an accusation against the Aurora in November 2010 [see attachment] alleging "repeated negligent acts." The Medical Board complaint alleges a "violation of the standard of care in a unit," indicating 22 that "Respondent was negligent in his care and treat- ment of [the patientl," and seeks disciplinary action (including possible license revocation/suspension). The California Board of Registered Nursing filed a similar accusation against an Aurora nurse in 2009 [see attachment] alleging acts of "gross negligence" and "incompetence" as contributory factors in the 2008 death of a patient at Aurora Las Encinas; that complaint seeks license revocation/probation." Of special interest, the CBRN complaint tiled with the Attorney General notes previous disciplinary actions taken against this Aurora nurse, including: "making false entries in hospital records [to obtain] a controlled substance and dangerous drug"; this disciplinary action was followed by a second instance of "obtaining and possessing a controlled substance." The CBRN complaint noted that both prior disciplinary actions resulted in license revocation (each revocation was subsequently stayed, with the nurse twice being placed on Eve years of probation). CBRN authorities took similar action against a second Aurora Las Encinas nurse, alleging "unprofessional conduct" and "gross negligence" in the 2008 death of a patient at the hospital. 24 California Attorney General Hlings in this case indicated a settlement in February 2011 [see attachment], with the nurse admitting to the CBRN allegations and accepting license revocation (immediately stayed, with the nurse receiving three years probation). 22 Medical Board of California; Case No. 11-2007-188043 California Board of Registered Nursing; Case No.2010-300 California Board of Registered Nursing; Case No. 2010-299 wi, pa 1 66 August 2008: A 14-year- old girl reports being raped in her room by a 16-year-old patient. Sources say hospital staffers were sleeping during the assault. Los Angeles 77mes; March 2, 2010 Eos Angeles Eimrs Timeline at Aurora Las Encinas Hospital March 06, 2010 December 2006! A 26-year-old patient who sought treatment for addiction, Leo Grassini, dies after staff members fail to check on him for 24 hours, despite a doctor's order that he be monitored very closely. November 2007: Grassini's father, Lawrence, alerts state and federal regulators, urging an investigation to prevent "future predictable deaths." April 2008! Jeffrey Hearn, 28, admitted for treatment of drug addiction, dies of an overdose of contraband prescription medications smuggled in by another patient. April 2008: Alex Clyburn, 23, is found dead in his room after being prescribed medication for drug addiction; staffers do not follow a doctor's order to continuously monitor him. May 2008: A memo from the nursing director warns staff members they can be fired if caught sleeping on the job. August 2008: A 43-year-old bipolar patient, Timur Otus, hangs himself with a plastic bag from the beam of a dilapidated shed. August 2008: A 14-year-old girl reports being raped in her hospital room by a 16-year-old patient. Sources say hospital staffers and the suspects probation officer were sleeping - during the assault. November 2008i Inspectors say the hospital could lose federal funding May 2009: Officials say the hospital is again under federal compliance. June 2009: A suicidal patient swallows a battery from a TV remote control. A week later, she breaks bathroom mirror and swallows shattered glass. August 2009: Chronic under-staffing has compromised patient care, former employees allege in a lawsuit against the hospital`s owner. 2009: A suicidal patient tries to hang herself, using the strings on a hospital gown tat have been attached to a faucet handle on a bathroom sink. She survives. January 2010: Federal officials say hospital may lose its federal funding. A .71nnua[Re]20rt 2oo5 A 0 'cs if* A _[tv F. 1 fee, 'Unite?{SLate5 Eastern District 64 Fraud against Medicare and Medicaid programs [by these Defendants] reached nearly $1 mi//ion. 99 lssues identified by authorities in Michigan. Aurora previously operated a 140-bed hospital in Detroit, which closed in 2002. CMS reports, federal court records and news media accounts indicated serious financial management and clinical quality of care problems at that facility; questions were also raised by federal and state law enforcement officials and health authorities about alleged irregularities in other aspects of corporate behavior: The U.S. Department of Justice filed a complaint against Aurora and its corporate ownership in 2005, alleging a conspiracy to commit fraud and "the submission of false [Medicare and Medicaid] claims. .. in contravention of the Fa/se Claims Act based on misrepresentations by [the Defendants]." The Los Angeles Times reported in a 2006 article that the Michigan case resulted in Aurora's owners subsequently paying a $1.73 million settlement in this case to the federal government." 26 0 The Ofhce of the United States Attorney for the Eastern District of Michigan later issued its 2005 Annual Report with the following section on United States of America v. Aurora Healthcare [page 381: Docton Companies, Sued for $1 Million Aurora Healthcare, lnc., was a non-protit hospital that provided services to Medicare and Medicaid patients. The United States intervened in this case. Defendant Soon K. Kim, controlled the operations of Aurora through a management team provided by Salem Service Company (Salem), a company which he owned. Kim and Salem report- edly caused Aurora to lease hospital premises from Michigan Mental Health Care Network, LLC (the "Network"), another company controlled by Kim, and to purchase other services from Kim-related companies. Notwithstanding Medicare and Medicaid guidelines that required participating hospitals to disclose and properly account for related party transactions. Aurora submitted cost reports tothe Medicare and Medicaid programs during the 1998 through 2000 cost years which failed to disclose Salem and the Network as related parties. Fraud against the Medicare and Medicaid programs reached nearly $1 million. United States of America v. Aurora Healthcare. Hled in US. District Court for the Eastern District of Michigan, Southern Division No. O1-741161, the UIC team was provided a copy of this complaint and other information courtesy of the United States Attorneys office in Detroit. 25 2? See: "Hospitals affiliated with Las Encinas also have been investigated"; Los Angels limes; March 3, 2009. "Staff not providing adequate care.._, The federal Centers for Medicare and Medicaid Services conducted a series of reviews at Aurora's Detroit facility prior to its closure. Some of the CMS Endings were later detailed in a Detroit newspaper, the Metro Times, which included comments from an interview, cited below, with a senior CMS Region 5 ofhcial in Chicago (Robert Daly) who oversaw the reviews: 27 Profit; me hospitals V. andonc ws* . docton .sm 'sms use- iifet ft .. 'ie "'1/fifd - 3 111 lltw- .l ff 4 Psi/ch* 77 an.. In es. wr.. ms: "tuna uvulvonv and not monitoring patients' behaviors, Daly said. As for lack of quality assurance, Daly explained, "Every hospital must have a system in place to review incidents, review procedures, improve operation, correct dehciencies, not wait fora survey to come along and point out problems. Daly said that when inspectors returned for a follow-up in August to see if the initial problems had been corrected, the sltuationu. had deterior- ated furthen "lt's not untypical to problems at hospitals, said Daly. "What is unusual is for there to be major issues and not have the problems But at Aurora, you had a situation where they were repeatedly failing to fix dehciencies. ln fact, they had even more problems in August than in January. Then a sun/ey in October still found problems. The August [2002] report [by is eye-opening. Federal inspectors found a facility in disrepair and a staff that frequently failed to ensure patients were safe and receiving proper treatment. There were not enough nurses, On weekends, only one was on hand to provide treatment for up to 140 patients, according to the report, At other times, were prescribing medica- tions but not delivering the that should have accompanied the drugs. Chemical restraints were being improperly used. Patients were staying in their rooms instead ot participating in treatment programs. Patients were being released without knowing where they'd go, Injuries among patients, whetherintlicted by fellow patients or by staff were on the rise. Aurora 's once sterling reputation was obliterated. 27 "Aurora Goes Dark:,Requiem for a Ward"; second of two parts in the Metro Times; January 15, 2003. See also, Tale of Two Hospitals." Metro Times, January 8, 2003! 9 i 1 OF Hrlufm AND HUMAN SERVICES TH rm 'crm _i -.fra-ew ru" .N ,t terturt-.rt Matt n-me rniti Aanlss Aunoim mc. 1737 Ds'rR0rr. onsficira um 7 ra mquitssau or mu man mdmammy zemq mv"-1 li mam mi arm. ie rm-. mm mum mar: at alrmimu-uuiumn arts: 1 mu me - mr were menu lntemas mssumum uw menus mt qw .mia un ,aa tl "try if .mewafru i meme: .menu w-1-u-was mums me .am i IM: Dunbar at pivthlallhits tx mi tg." ewes or iam Til Amr sm-"fr i Hill?" wt . .i t. -_em i Wa fmmu as iwluxlr./t iv r' :aww :murmur -mt -. er I :t F4- uevsx -aw me Tm -mae.: 1 .ia avramu names nw an ,mama we ,au A um, tt ut .it ,twat zrwawf. -emiasana nunayv rm.-ma. cum Hu llc; fill! in .ri wit". few" :nun vuilr Lani" i What the UIC reviewers found so remarkable about these particular news media accounts - and the reason they are cited at length in the current report - was the tone of the comments attributed to the CMS official in discussing the findings by the Federal surveyors over a protracted period. Generally speaking, mid-level regional officials in Federal agencies do not give news media interviews - certainly not using the sort of blistering terms this official chose to describe a sense of frustration that CMS staff apparently felt in dealing with a repeated pattern of non-compliance, harm to patients and failure to ensure quality of care standards. In light of the corroborating data found in the original 2001- 2003 CMS reports/correspondence on the Aurora facility, several brief examples about Aurora's Detroit operation - highlighted on this page and in the attachments -indicate the basis of frustration with this corporation." ln the partial clips highlighted in the column to the left, the CMS sun/eyors cited Aurora ofhcials for failure to monitor the quality and appropriateness of services and treatment provided by the medical staff, as required under 42 CFR ?482.62(b) pages 7-8 of 21]. This particular deficiency arose from the finding that "the number of [was] not adequate to provide essential as evidenced in part by the discovery that "the weekend provides treatment for.., up to 140 patients," which the CMS surveyors indicated was "not sufficient to provide essential se/vices." Similar deficiencies were discovered with regard to: inadequate nursing stafing [42 CFR quality assurance [42 CFR ?482.21]; discharge planning [42 CFR ?482.43]; patients' rights [42 CFR ?482.13]; and special staff requirements for hospitals [42 CFR ?482,62] -to cite a partial list of the serious problems that were identified on a recurring basis at this Aurora-owned hospital. Perhaps the most instructive item in understanding the efforts by Federal authorities to bring this hospital into compliance, however, is a January 2002 letter from a CMS official to the CEO of the Aurora/Detroit facility: "Since Aurora Healthcare has continued to provide a non-credible allegation of compliance, CMS has no choice but to terminate the hospital's participation in the Medicare [emphasis added]. 2" The UIC reviewers obtained original CMS survey reports and related correspondence regarding Aurora/Detroit by a Freedom of information Act request to the CMS Region 5 office in Chicago [see annotated attachmentsl. 3 Michigan Qui; il A f/ "un-I' Also ofinterest, following the Department of Justice action (in 2005) the Ofhce ofthe Attorney General of Michigan ordered an investigation into illegal dumping and open burning of medical records in a vacant lot by officials from another Detroit hospital controlled by Aurora Healthcare (operating in this instance under the corporate name Signature Healthcare). An official with the Department ot Community Health stated: This incident is the most egregious case we have ever witnessed in this state, and those persons responsible need to ., answer for their actions." Michigan's subsequent two-count court action - filed in 2007 against both the corporate owner, Dr. Soon Kim, and Signature Healthcare - alleged that: 1. This complaint for injunctive relief, damages, and civil fines arises out ofthe mass dumping, mishandling Attorney General of State of 1 and burning of medical records, x-rays, hospital manuals, financial records, and other 2. The records, which were dumped in a mannerthat left them accessible to passers-by, contained names, social security numbers, x-rays, test results, and other highly sensitive information related to former The accompanying press release announcing the court action noted remarks about this case by the Michigan attorney general: "People have a right to know that their medical records are kept safe and Beyond disposing of these records improperly, these individuals' actions place patients' persona/ and private medical information at risk. Those responsible should be punished to the fullest extent of the law. 29 In sum, both the Department of Justice actions as well as the CMS Endings (regarding the operation of Aurora-owned hospitals in California and Michigan) are directly relevant to the current evaluation -that is, insofar as such background information sheds light on the corporate context in which CLH officials make decisions and structure the delivery of services for DCFS wards. 3? 29 Office of the Attorney General of Michigan; press release on October 3, 2007; the Michigan complaint was later settled with a fine of $40,000. 3? By no means should this be interpreted as questioning the integrity of local Aurora officials at CLH, where evidence suggests they make every effort to do their best with limited resources; it does, however, underscore the need for DCFS to focus continued scrutiny on the treatment its wards receive when they are hospitalized at this Aurora-owned facility. A Se|ected case reviews This section will briefly detail certain quality of care concerns that were identified by the UIC team during the course of examining of DCFS wards at CLH medical charts, treatment/discharge plans and other records on the sample of DCFS wards admitted to CLH during the 30-month period from January 2008 through July 2010; the six cases below were selected to illustrate a range ofthese quality of care issues. Case 1: MG MG, a 12-year-old boy admitted to CLH on 6/7/10, has three prior hospitalizations (including Riveredge in 2007, followed by Streamwood and Hartgrove earlier in 2010). The admission note indicated that at the time of admission to CLH he was actively halluclnating and posed a danger to self and others. When the UIC team initially reviewed MG's records in late-August he had been at CLH for 84 days, during which time he received a total of 83 emergency medications (34 in June, 24 in July and 25 in August). The UIC team notitied the DCFS clinical division because of concems about the frequent use of emergency medications, and a stafing was subsequently held on 9/18110.31 UIC subsequently reexamined the emergency medication records for MG during his 113-day hospitalization when questions arose about the way these medications were administered and charted. As shown in the summary table below, that reanalysis indicated a signiticantly higher usage of emergency medications with MG than was previously thought: specifically, a combined total of at least 180 emergency medications (112 PO) during the period from June 7 to September 27 [see Table 1, below].32 The UIC reviewers identified additional quality of care concern regarding MG's treatment at CLH: First, and of most concern, despite the fact that MG continued to exhibit a range of severely disruptive behaviors -including aggression and emotional dysregulation presumably serious enough to require 180 emergency medications in 113 days - a day-by-day review of his chart suggests, at best, clearly ineffective pharmacotherapeutic management of this case. 31 The DCFS clinical staffing recommended that be transferred to the CATU program at UIC, which was done on 9/28/10; total length of stay at CLH for MG during this hospitalization was 113 days, primarily due to the difficulty DCFS had in identifying an appropriate discharge placement. 32 By way of comparison, in the 100-day period following transfer to CATU, MG received less than a half-dozen such emergency medications -that is, a frequency approximately 30 times /ess than he was administered at CLH. I Second, the treatment team requested testing (late in the hospital stay) that documented the patient had mild mental retardation (FSIQ 69). No mention of this data was incorporated into the clinical formulation in the treatment plan, however, nor was there evidence that the team used this new information to help the unit's direct-care staff understand how MG's cognitive and language deficits affected his behaviors. - Third, the clinical team repeatedly failed to modify MG's treatment plan even after it was evident that the initial plan, including medication management, was not effectively addressing the patient's disruptive behaviors. 33 Finally, even though the admission note indicated that MG had been experiencing command hallucinations prior to admission to the hospital, neither the treatment plan or discharge summary indicated as a clinical problem to be addressed during the hospitalization. 34 33 It is troubling that the inordinately high usage of emergency medications in this case did not appear to trigger an internal review at some point, either within the treatment team itself or by the quality assurance process ofthe medical executive committee. As indicated above, the UIC team identiied the emergency medication through its chart reviews of selected cases, but Dr. Naylor had also independently discovered this emergency medication trend in the clinical database. 34 Dr. Naylor, in his role as consultant for the UIC Mental Health Policy Program, discussed the issues of MG's case with the CLH medical director by telephone as well as during the exit interview with CLH ofhcials on December 20 he also discussed the case management issues at length with MG's attending Dr. who agreed that such fre uent utilization of emergency medications was not ideal. Ot interest, Dr. 's explanation ofthe behavioral problems MG displayed on the unit was that his outbursts were volitional, largely due to his frustration about his length of stay, which was considerably longer than other patients. Dr. stated that towards the end of |v|e's hospital stay at CLH the treatment team initiated a new behavioral intervention (not documented in the chart) in which MG's prosocial behaviors were rewarded (by allowing him to watch football and engaging him in other football-related activities). By her report, the frequency of emergency medications subsequently decreased following implementation of the plan; this is corroborated by the record of emergency medication administration, As for the problem of MG's cognitive deficits, the attending stated that the treatment plan was not updated to reflect these deficits because the results of the testing came just before discharge. While the severity of MG's mental illness - recurrent episodes of explosive outbursts of agitation, and mood that appear to have a cyclic component- would create a challenge in any therapeutic setting, it is troubling that his treatment for prolonged periods of time at CLH appears to have centered on behavioral management by emergency medications, with no clear behavior plan and ineffective or uninspired pharmacotherapy. Table 1: MG's emergency medications at CLH 3 Date/Time 06 0710 1050 am 060710 1050 am 060710 6pm 060710 6pm 06 0810 2 50 060810 250 pm 060810 905 pm 060910 1015 06 0910 1015 06 0910 061010 930 pm 061110 1045 am 061110 1045 am 061110 03 20 am 061110 03 20 am 061110 930 pm 061310 430 pm 061310 04 30 pm 061310 Medications Thoraz|ne 50 mg Benadryl 50 mg Thoraz|ne 50 mg Benadryl 50 mg Thoraz|ne 50 mg Benadryl 50 mg Benadryl 50 mg Thoraz|ne 50 mg Benadryl 50 mg Benadryl 50 mg Benadryl 50 mg Benadryl 50 mg Thoraz|ne 50 mg Benadryl 50 mg Thoraz|ne 50 mg Benadryl 50 mg Benadryl 50 mg Thoraz|ne 50 mg Haldol now (4) iivi new (5) IM now (6) PO n0w#1 irvi now (now (10now (11) IM now (12) IM now (13) Table 1 is a daily chart summary of emergency medications, including dosage levels, administered to MG during his 113-day hospitalization at CLH. While the chart and MARS indicated that at least 11 - including the CLH medical director, attending and fellows -ordered these emergency medications at various times. there was little evidence that MG's treatment team attempted to address the protracted use of such medications as a therapeutic issue. 35 06.13. 7pm 061310 915 061410 10am 061410 10am 061610 061610 061610 12 20 061610 12 20 061810 7 20 061810 7 20 |11 061910 8am 061910 8am 062010 06 2010 6 05 062110 9am 062110 9am 06 221021 B30 am 062210 830 am 062310 7 55 ITI 062310 755 pm 06 2510 930 am 062510 930 am 06 2510 640 pm 06 2510 Ativan 1 mg. Benadryl 50 mg Benadryl 25 mg Thorazme 25 mg Benadryl 25 mg Thorazme 25 mg Benadryl 25 mg Haldol 5 mg (2) Haldol 5 mg Benadryl 25 Benadryl 25 mg Haldol 5 mg (3) Haldol 2 mg Benadryl 25 mg I-|a|do| 5 mg Benadryl 50 mg Haldol 5 mg Benadryl 50 mg Haldol 5 mg Benadryl 50 mg Haldol 2 5 mg Benadryl 25 mg Haldol 2 5 mg Benadryl 25 mg IM now (14now (15) IM now (16) IM now (17) IM now (18) PO now IM now (19) IM now (20) PO now PO now IM now (21) IM now (226:05 640 pm Haldol 2.5 mg, 8 am Benadryl 50 mg. 8 am 3:30 3:30 pm Haldol 5 mg. IM now (23) 11:45 am 11:45 am 06.27.10 Thorazine 25 mg. PO now -2 Benadryl 25 mg 1 4:30 pm 4:30 pm 5:45 am 12" 8:45 am 06.29.10 Haldol 5 mg. IM now (29) -- 9 am Thorazine 50 mg. PO now 5:25 5:25 pm 4:20 4:20 pm 5:45 Benadryl 07.05.10 Thorazine 07.05.10 Benadryl 1:50 1:50 10 10 8:15 B115 07.11.10 Thorazine 50 mg. IM now (5) 2:15 pm 07.11.10 Benadryl 50 mg. IM now (6) 2115 IT1 07.17.10 Benadryl 25 mg. PO now (10) 06:20 07.17.10 Thorazine 25 mg. PO now (11) 06:20 07.20.10 Thorazine 50 mg P0 now 6:15 12) 6:15 07.21.10 Benadryl 50 mg. PO now (14) 1:50 pm 07.21.10 Thorazine 50 mg. PO now (15) 1Z50 07.23.10 Thorazine 50 mg. IM now (7) 7:30 07.23.10 Benadryl 50 mg. IM now (8) 7:30 pm 07.24.10 Benadryl 50 mg PO now (16) 9 pm 07.25.10 Thorazine 07.25.10 Benadryl 50 mg. IM now (10) 07.26.10 Thorazine 25 mg. IM now (11) 12:15 pm 07.26.10 Benadryl 25 mg. IM now (12) 12:15 pm 07.27.10 Thorazine 50 mg. IM now (13) 5:20 pm Mm-. V, I 07.27.10 Benadryl 50 mg. IM now (14) 5:20 pm 07.28.10 Thorazine 50 mg. PO now (17) 6:50 pm 7.28.10 Benadryl 50 mg. PO now (18) 6:50 07.29.10 Thorazine 50 mg. IM now (15) Benadryl 50 mg. IM now (16) 12:45 pm 07.29.10 Thorazine 50 mg. IM (17) 4:30 pm 07.29.10 Benadryl 50 mg. IM (18) 4:30 pm 07.30.10 Thorazine 25 mg. IM (19) 12 pm Benadryl 25 mg. IM now (20) 12 pm 07.30.10 Thorazine 50 mg. IM now (21) 8:10 07.30.10 Benadryl 50 mg. IM now (22) 8:10 pm 07.31.10 Thorazine 25 mg. IM now (23) 9:15 am 07.31.10 Benadryl 25 mg. IM now (24) 09.15 am 4:15 07.31.10 Benadryl 25 mg. PO now (20) Q- 07_31.10 Thorazine 25 mg. IM now (25) 6 pm 07.31.10 Benadryl 25 mg. IM now (26) 6 pm 08.01.10 Thorazine 08.01.10 Benadryl 11:30 am 08.02.10 Benadryl 25 mg. IM now (4) Haldol 5 mg. IM (5) 5:45 pm 5:45 pm 08.03.10 Thorazine 50 mg. IM (7) 5:30 pm 08.03.10 Benadryl 50 mg. IM (8) 5:30 08,0310 Haldol 5 mg, IM (9) 06:45 08.03.10 Cogentin 1 mg. IM Stat (10) 06:45 08.08.10 Thorazine 50 mg. IM Stat (11) 9130 08.08.10 Benadryl 50 mg. IM Stat (12) 9230 08.09.10 Ativan 2 mg. PO now (1) 2:45 ITI 08.09.10 Haldol 5 mg, IM stat (13) 4:30 08.09.10 Cogentin 0.5 mg. IM stat (14) 4:30 8 08.09.10 Benadryl 50 mg. IM stat (16) 8 TTI 08.12.10 Haldot 5 mg. IM x1 (17) 12:40 pm 08.12.10 Ativan 2 mg. IM x1 (18) 12:40 pm 08.12.10 Thorazine 50 mg. IM now (19) 2:30 08.12.10 Benadryl 50 mg. IM now (20) 2:30 08.12.10 Thorazine 50 mg. IM x1 now (21) 8:45 pm 08.12.10 Benadryl 50 mg. IM x1 now (22) 8145 08.13.10 Haldol 5 mg. IM now (23) 10 am 08.13.10 Benadryl 50 mg. IM now (24) 10 am 08.14.10 Cogentin 2 mg. IM now (25) 9:15 am 08.17.10 Thorazine 50 mg. IM x1 now (26) 1:30 pm 08.17.10 Benadryl 50 mg. IM x1 now (27) 1:30 pm 08.17.10 Thorazine 50 mg. IM x1 now (28) 4:15 pm 08.17.10 Benadryl 50 mg. IM x1 now (29) 4:15 pm 08.18.10 Benadryl 50 mg. IM x1 dose (30) 11:45 1 2 08.18.10 Thorazine 50 mg. IM X1 dose (31) 11:45 pm 08.19.10 Benadryl 50 mg. IM x1 now (32) 08.22.10 Benadryl 50 mg. PO now x1 (2) 12:15 am 08.23.10 Benadryl 08.24.10 Benadryl 50 mg. PO x1 now (4) 12:50 am 08.24.10 Benadryl 50 mg. PO x1 now (5) 10:20 08.27.10 Thorazine 50 mg. IM x1 now (33) 9140 pm 08.27.10 Benadryl 50 mg. IM x1 now (34) 9:40 pm 08.28.10 Thorazine 50 mg. PO x1 now (6) 6:00 08.28.10 Benadryl 50 mg. PO x1 now (7) 6:00 pm 08.30.10 Benadryl 50 mg. PO x1 now (8) 12:00 am 09.02.10 Thorazine 50 mg. IM x1 now (1) 4:30 pm 09.02.10 Benadryl 50 mg. IM x1 now (2) 4:30 09.05.10 Thorazine 50 mg. PO x1 now (1) 4:25 09.05.10 Benadryl 50 mg. PO x1 now (2) 4:25 pm 09.07.10 Thorazine 50 mg. IM x1 (3) 2:15 09.07.10 Benadryl 50 mg. IM x1 (14) 2Z15 09.07.10 Thorazine 50 mg. IM x1 now (15) 6:45 pm 09.07.10 Benadryl 50 mg. IM x1 now (16) 6:45 pm 09.11.10 Thorazine 50 mg. PO x1 now (3) 11:00 pm Benadryl 50 mg. PO x1 now (4) 11:00 pm 09.12.10 Thorazine 50 mg. IM x1 now (17) 9:30 am 09.12.10 Benadryl 50 mg. IM x1 now (18) 9:30 am 09.12.10 Thorazine 50 mg. IM x1 now (19) 7 pm mm 1 'nw 091210 7 091310 6 30 091310 630 pm 091310 715 pm 091310 715 pm 091610 10 05 am 091610 10 05 am 091710 091710 510 091710 820 pm 091710 820 pm 092010 10 45 pm 092010 1045 pm 092110 430 092410 5 092410 5pm 092710 Benadn/I 50 mg Thorazme 50 mg Benadryl 50 mg Thorazme 50 mg Benadryl 50 mg Thorazme 50 mg Benadryl 50 mg Thorazme 50 mg Benadryl 50 mg Haldol 5 mg Benadryl 50 mg Thorazlne 50 mg Benadryl 50 mg Thorazme 50 mg Thorazme 50 mg BenadryI 50 mg Benadryl 50 mg IM x1 now (20stat (21) IM stat (22) IM (23) IM (24) IM x1 now (25) IM x1 now (26) IM x1 now (27) IM x1 now (28) IM stat (29) IM stat (30(31) IM x1 (32Case 2: PC PC is an 11-year-old boy with one prior hospitalization in 2008 (19 days at Haitgrove) before his admission to CLH in mid-August 2009; he remained hospitalized at CLH until mid- January 2010, for a total of 154 days, apparently because DCFS could not ind an appropriate discharge placement. Based on the review of PC's medical records at CLH, this case - and to some extent the case ot MG, cited above - should be viewed as instructive for DCFS as a worrisome example of the systemic failure to ensure that such youths do not languish in hospitals for reasons unrelated (or secondary) to the mental illnesses that originally prompted their admissions to inpatient care. Shortly after PC's admission to CLH, for example, the initial stafting notes indicated the need for a residential facility as a placement following discharge. Over the course of the next tive months, DCFS made Eve referrals to residential facilities before PC was accepted; dunng this five-month waiting period, PC's clinical condition was observed to deteriorate (as indicated in various chart notes by CLH clinical staff). Approximately four weeks later (9/24/09) a CLH staffing note indicated that PC was decompensating on the unit and was expressing anxiety about where he would be placed next. - CLH progress notes indicated that the hospital social worker repeatedly contacted or left phone messages with a DCFS representative about the ongoing lack of progress in Ending a discharge placement for PC. - On a progress note indicated "Pt is very unsettled about being here (in hospital) for so long." This is followed by a series of progress notes in December: "Pt presents as depressed and frustrated due to placement issues"; "Pt's [aggressive] behaviors are exacerbated by the placement "Pt presented with depressed because of being in the hospital for Christmas hoIidays"; "Pt admits to getting frustrated, especially since he has been here 112 days due to placement issues." ln January 2010, PC wrote the following comments as part of a writing assignment: "This book is about this kid who is so bored and did not know what to do. How it relates to me is because sometimes lam also because there is hardly nothing to do around here. It was about a boy who was watching TV and was still bored out of his mind." Apart from the systemic issues interfering with PC's treatment, the UIC reviewers identitied several areas of concern regarding the inpatient services provided to this ward at CLH: Notably, the attending physician documentation in the chart was inadequate; very rarely was there any subjective report from the patient, and most notes appeared to be abstracted from the information already presented elsewhere in the chart; the mental status reviews were quite superficial and appeared to change little from day to day; similarly, the treatment plan was very superficial and not instructive to clinical staff. UIC reviewers found 38 notes by the attending that did not indicate time or content of the interaction with the patient, as required by federal Medicaid regulations; in fact, the most common notation was to "cont. Tx plan." 3? Additionally, no attending notes were found in this chart for the 24-day period between 11/5/09 to 11/29/09. Also of concern, the UIC team identified atleast 18 instances where nursing staff may have failed to ensure that this patient received his medications - Lithium, and in one instance Abilify - as evidenced by unsigned MAR documents. Similar problems regarding medication administration records were noted in charts of other patients during the UIC review. 37 Treatment plan deficiencies were also noted with regard to medical issues present at admission, including encopresis and enuresis; a review of PC's medical records, however, showed that these issues were not effectively addressed within the treatment plan. PC was tinally discharged in January 2010 to a residential placement setting. As indicated elsewhere in the current report, CLH medical records were found deficient in numerous areas regarding basic clinical documentation, including: multidisciplinary treatment planning, discharge planning, progress notes and medication administration records. See especially footnotes 10 11, above, regarding similar findings by JCAHO. 36 37 UIC reviewers see this issue, in part, as related to the fact that CLH does not utilize an electronic medical system on the units - meaning that nursing staff and physicians are required to spend inordinate amounts of time doing their medication charting and progress notes by hand, a systemic problem that likely contributes to such errors. [See page 13, above, regarding efforts by CLH administrators to obtain an electronic data system for the hospital from Aurora corporate-level officials] Case 3: DB DB is a 17-year-old boy who has been admitted to CLH on six occasions from Lawrence Hall Youth Services since 2009; the third and fourth readmissions in 2009 occurred approximately one week following discharge from CLH. The UIC reviewers identified several areas of concern regarding DB's treatment at CLH: - Four of the six CLH treatment plans for this youth appeared boiler-plated, possibly because the nurse who completed the ITP form had not read the clinical information available from admission. For example, in one treatment plan - as well as in the initial assessment, social assessment and discharge summary -there were no references made to DB's high-risk behaviors (persistent suicidal ideation and gestures throughout his admissions, impulsivity and aggression), while another plan contained no reference to his explicit threats to kill his mother and her boyfriend. Similarly, RN daily assessments, daily flow sheets, and the points and levels worksheets also appeared boiler-plated (most of the latter, for example, were not completed by staff on the PM shift). Social work documentation in the charts was sparse, at best, since individual and group contacts with the patient were not recorded; further, there appeared to be only one social work progress note during these six CLH admissions. - On a positive note, frequency of contacts with this patient appeared good in four of the six charts reviewed; additionally, the length of time spent with the patient was usually indicated in these charts (possibly because revised hospital fom1s now prompt for that required information). Finally, three of the six discharge summaries for DB were written in a thorough manner, with appropriately detailed clinical information that would be useful to other providers; the other discharge summaries were somewhat inconsistent in quality discharge medications were missing in one case), but for the most part these were relatively minor and correctable problems. 3? Reference is again drawn to footnote 12, above, which cited a 2008 CMS report on CLH that identihed certain deficits regarding discharge/aftercare issues -including the content, accuracy, timeliness and quality monitoring of patients' treatment plans, evaluations and other medical records. ln light of the multiple admissions often experienced by DCFS wards - at all hospitals utilized by the Department, not just CLH - it should be understood that the UIC team focuses on such "paperwork details" as one element in an integrated quality of care review. 35 Case 4: JD JD is a 15-year-old boy who has been admitted to hospitals approximately 16 times since 2003, including six CLH admissions from LHYS between late-2008 and mid-2010. The UIC reviewers identified several areas of concern regarding JD's treatment at - JD is reportedly allergic to Thorazine, as documented in each of his six CLH charts; however, on his tirst admission (2008) he was administered a stat dose of Thorazine, despite the fact that his allergy was noted in at least a half-dozen points in the chart history and physical, nursing assessment, initial evaluation, MARS, etc.).39 The attending noted that "the patient received stat medications twice du/ing the admission for agitation." Immediately after this statement, however, the struck-out/initialed part of the paragraph, as follows: . He was closely monitored after receiving the Thorazine dose and did not show any signs or of intolerance or allergies to the Thorazine. The patient tolerated his medications well. He did not require restraints during the admission, The then added the following comment: "Patient Hllegiblej during one of his agitated episodes despite his protests that he was allergic. Patient had received Thorazine in the past without adverse effect." This was JD's first admission to CLH, and his chart contained no indication wholwhat the source was for asserting that he had previously tolerated Thorazine "without adverse effect." Multidisciplinary treatment plans during these six admissions were inconsistent in clinical quality and thoroughness from one hospitalization to another; some of the treatment plans appeared boiler-plated, and one was simply copied from a prior PHP (partial hospitalization program) stay. Of interest, progress notes documenting JD's participation in the PHP totaled less than one page for an eight-day period. A medication error occurrence report, dated 1O,7l08, indicated three staff responsible for this incident: two RNs and the attending 39 Case 5: AG AG is a 15-year-old boy with six admissions to CLH from LHYS between 2008-2010; two of the three 2010 admissions occurred within a few weeks following discharge from the prior inpatient stays at CLH The UIC reviewers identiied several areas of concern regarding AG's treatment at CLH: - As was seen in other cases, the multidisciplinary treatment plans for this patient appeared boiler-plated at times, with minimal clinical details and inadequate case formulation. For example, while AG has been aggressive in residential settings, he tends not to display these behavioral problems in the hospital; nevertheless, aggression was identitied as the primary focus of one treatment plan to the exclusion of other major problems (such as medication non-compliance, runaway behaviors and high-risk sexual conduct). - Similarly, the content of assessments and progress notes during certain admissions tended to show an overreliance on the patient to provide information, despite the fact that AG often gave contradictory information or was uncooperative. lt is worth noting that the quality of multidisciplinary treatment plans and other clinical documentation during some of these six admissions has ranged from inadequate to incomplete; the more recent (2010) hospitalizations, however, showed improvement with regard to progress/discharge notes, suggesting a commendable effort on the part of CLH ofHcials (as indicated in minutes of the Medical Executive Committee) to pay closer attention to such problem areas." "1 For example, progress notes in the February and June 2010 charts demonstrated therapeutic rapport with the patient and, unlike some previous admissions, it was clear that the had actually met with the patient to address treatment issues (such as medication non-compliance and repeated hospitalizations). 41 As noted earlier in footnote 11, the UIC reviewers and JCAHO surveyors found significant problems with progress notes and other areas of medical documentation that are the primary means of evaluating what is occurring in treatment and ensuring that patients are receiving quality care. In April 2010, for example, the JCAHO surveyors noted patient charts that there were "incomplete and had omissions of who/e sections of information, and/or blank spaces for required information"; UIC reviewers also identified similar deficiencies in a sampling of CLH charts that was considerably larger than the JCAHO sample. mmf. M.-mt Conclusions Recommendations Summary of findings and conclusions. The UIC review conducted at Aurora Chicago Lakeshore Hospital identified certain clinical and facility performance issues that raise concerns about quality of treatment services provided to DCFS wards, with particular reference to a pattern of corporate-related quality of care issues beyond this single Illinois hospital. As was shown, some of UlC's observations at CLH were echoed in the findings of surveys undertaken by the Illinois Department of Public Health (conducted on behalf of the Federal Centers for Medicare and Medicaid Services) as well as the Joint Commis- sion on Accreditation of Healthcare Organizations, each of which touched upon similar quality of care issues. Moreover, such issues are of special relevance for the current review in light of the pattern of harmful incidents and quality of care deficiencies that reportedly occurred at hospitals operated by the Aurora corporation in California and Michigan, as noted, in both states this corporation has also been the focus of investigative scrutiny by state and Federal law enforcement and/or healthcare authorities, as well as extensive news media coverage about substandard quality of care and harm to patients. Public policy implications for DCFS. insofar as the current UIC report is likely the first time that the Department has been informed about any of these worrisome situations involving Aurora's problems in other states, it does not seem either unreasonable or unfair to conclude that Aurora's corporate officials assumed the position that they have no ethical obligation to fully inform DCFS of any adverse events beyond the limited scope of Illinois' mandatory reporting regulations. '2 Simply as a matter of public policy and its Hduciary duty of care, however, DCFS has a special interest in learning whether one of its child welfare or mental health providers may have a history of the sort of non-compliance or substandard performance regarding healthcare standards that are detailed in the current UIC report. Arguably, the Department has a right to expect that its providers will normally act in good faith by informing DCFS if any of their programs become involved in such adverse events, including negative news media coverage. Stated simply: the lack of such transparency often means that decision-making ability to ensure the safety of its wards is severely compromised." 42 Aurora's corporate officials are not alone in assuming a transparency- averse position, as DCFS has learned from dozens of previous UIC reviews of hospitals since 1994. "3 Given that corporate interests tend to inhibit transparency, DCFS has a fiduciary responsibility to initiate whatever inquiries that may be necessary to obtain all relevant information about the performance history and general trustworthiness of any corporation that seeks to provide services to DCFS wards; nor is that responsibility diminished when adverse events occur in other states and/or may not directly involve DCFS wards per se. In sum, while the primary focus of this review was on the quality of care and treatment services delivered to DCFS wards at CLH, the UIC team concluded that the available data about Aurora's corporate history over the past decade were equally relevant - and certainly more worrisome - with regard to the overriding issue that the Department must confront on a daily basis: that is, whether DCFS can have a reliable level of confidence and trust in the ability of a service provider to consistently offer adequate and effective care in a therapeutic environment that keeps its wards safe from harm. Despite the fact that Aurora's corporate history does not inspire that sort of high confidence level, the UIC team was mindful of the fact that CLH officials and professional staff at the local level appear to struggle against an array of impediments to their ability to provide quality of care for patients in a safe environment." 4? lnsofar as certain identified clinical or quality performance issues at CLH were viewed as contributing to recurring problems within the hospital- such as inadequate staffing levels, poor supervision of staff and inconsistent monitoring of patient safety -the UIC review has shown that similar problems were previously identiied by different sets of reviewers in other Aurora-operated hospitals, suggesting that the root causes of these deficiencies can likely be attributed in large part to a dysfunctional corporate context. 44 Simply stated, the UIC team could not ignore either the corporate history or the corporate context in which CLH must operate as an Aurora facility: Of most immediate concern is the fact that federal CMS ofhcials in California recently found the recurring problems at one Aurora hospital in Los Angeles so serious that they twice initiated actions to decertify the facility from participation in the Medicare and Medicaid programs. Related to these identified quality of care problems, the Medical Board of California and the Board of Registered Nursing initiated disciplinary action against a and two nurses reportedly involved in the deaths of two patients at Aurora Las Encinas Hospital. Similarly, Department of.lustice ofhcials in Michigan tiled a federal court complaint against Aurora's corporate owners - alleging false claiming and a conspiracy to commit Medicaid fraud - leading to a settlement of $1.73 million paid to the government. 45 Of special note, the UIC team was impressed by the willingness of CLH direct-care staff- both in their 2009 survey comments (some of which were presented on page 14) and in confidential interviews -to identify many of these structural impediments. Throughout the current report, therefore, the UIC team attempted to underscore what were also identiied as institutional within CLH. Special reference was made to nursing leadership, several of whom have been at CLH for more than 20 years and who provide a critical measure of stability and experience to the hospital's operations. Similarly, the UIC team found that the unit-level nurse managers were generally knowledgeable, caring and skilled professionals. Recommendations. Finally, the task of assessing how the Department should proceed with regard to DCFS wards at Chicago Lakeshore Hospital can be framed from the perspective of the CMS official, quoted earlier, who sounded a cautionary note in a remarkable 2003 interview about Aurora's intractable problems in Michigan: "Every hospital must have a system in place to review incidents, review procedures, improve operation, correct deficiencies, not wait fora survey to come along and point out problems." not untypical to find problems at hospitals. What is unusual is for there to be major issues and not have the problems hxedu. But at Aurora, you had a situation where they were repeatedly failing to Hx deficiencies. ln fact, they had even more problems in August than in January. Then a sun/ey in October still found problems. The implications of the quality of care issues identified at CLH, as well as the corporate history of Aurora, therefore suggest a need for DCFS to continue conducting unannounced reviews at this hospital over an extended period, with special focus on the issues of ensuring effective staffing levels, staff supervision and monitoring of patient safety. While the UIC team has no doubt that CLH officials intend to implement corrective action measures around these identified quality of care issues - indeed, it is likely they have already taken certain steps as a result of the December 20 meeting with UIC - the Department's fiduciary duty of care requires that it not rely entirely on quality assurance systems operated by its service providers, especially when those accountability mechanisms have proven so woefully deficient in the past. 'Pl- List of Attachments Centers for Medicare Medicaid Services: Selected reports on Aurora-operated hospitals in Illinois, California and Michigan United States Attorney's Office for the Eastern District of Michigan: 2005 Annual Report Federal Court complaint: United States of America ex rel. Clark v. Aurora Healthcare Office of the Attorney General of California regarding: Medical Board of California; Case No. 11-2007-188043. 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PM 1>>oquaannum pam ,mm mm: =,sz mama naw: mm; uma" pm mama Qnqauq ww-, . ., fn., Wm., U.. mf. m-.1 .mmq ,n -"un 1, ww wma vu up =m|pv, mp nm ww, an a--as -sn/uv .m .M sm-mswoma wrwiwo an mum mama: sul wma umm: au 1 .wnen :mm uumupuuwfmu vw- Au. wr p- nw (au hp" mm, Wpanpn. m--M w- \-mm-1 ,mum .W me-4| mm," in c-ww-w MM ,ohm ww 15; Mm iq; im," mn pu. am mm wwuung. mr Sn sz annum., iv/_ Dil Ol M1 $0 IIGIVVBIU 911 QIVIICWMV Nl Ol WJ Dil WULYWIQMU mumsNYU SIWINQI GK CII) wuason sm vuounv 1v Hsvnuw; sv1 vuounv am: ww un a aasz cum wvnan noe: I anon an ims 'un mmuv nm; mums so an mm ma: ?z 'sms 'ua 'ssmm mm nnunsw mwaua fo ww: .-- -l MW ILDUSO uumwo: -unvuw ummummn uoumwoa ow I ~ou>mo> um mv I (IU AMHDSIIVCIFM7 (Ili "Ii QDIIDWIIVIS 9 SUIINZD BWO SSDIAHES GNV 10 GZAUYIMV (INV H.L1V3H 10 iff f-5~ I *tif ww-- Qjfise Qfji/Ei5faf1g?; 2@ Tabi? of Contents Dedication to Michele Tomsho Letter from the U.S. Attorney Biography of the U.S. Attorney History of the United States Attorney's Office Office Structure 2005 Case Highlights Cou nter-Terrorism Major Narcotics Cases White Collar Crime Prosecutions Violent Crimes Project Safe Neighborhoods Protecting Children from Exploitation Child Pornography Tax Fraud Public Corruption and Special Prosecutions Civil Rights - Criminal Enforcement Labor Racketeering Organized Crime Environmental Crimes Civil Division Cases - Defensive Litigation.. Civil Division Cases - Affirmative Litigation Community Partnerships "ilntted'Smfe_r Qijttce ji/lEUR6??6L7f@ ?P1'0cee0t? Seized jfrorn Horne }[ea[tPi C6578 Owners Elena and David Szilvagyi, owners of Prime Care Services lnc., a home health care agency (and several other related corporations) defrauded Medicare of an estimated $836,000 pursuant to the submission of false annual cost reports. Fatsely obtained Medicare payments were used by defendants to build their lavish private residence in Clarkston, Michigan. Pursuant to the False Claims Act, the government brought suit seeking treble damages and seized approximately $650,000 in a pre-judgment garnishment action under the Federal Debt Collection Procedures Act. Defendants entered guilty pleas in a parallel criminal proceeding brought in the a judgment in the amount of $864,818.68, which was collected through an administrative offset. United States in Amr and Medical Supply inc. Doctor", Companies, itz [Il/Ziffioifi. to Common. Aurora Healthcare, Inc. (Aurora), was a non- profit hospital that provided services to Medicare and Medicaid patients. The United States intervened in this case. Defendant Soon K. Kim, controlled the operations of Aurora through a management team provided Western District of Michigan and . I by Salem Service Company are currently sewing 48- and ig: (Salem), a company which 30-mG!tTh pl'iSOl'1 he own-3d_ Kim and Saiem sentences. ln October, reportedly "Used Aurora the court ordered the to lease hospital premises Couple to Pay $2-5 millivn after granting from Michigan Mentai Health care the governments motion for summary i" Network, l_l_C (the "Netvvork"), another iUdQm@Vli the Civil il'\ the EESYQTU company controlled by Kim, and to purchase District, based upon defendants' guilty pleas. other services from Kim-related companies. United States in Szilvagyi et al. Notwithstanding Medicare and Medicaid guidelines that required participating hospitais for etture ?\/Mae chair Comjoamf Owner' to Qive 'Up $1 .Million This was a civil False Claims Act proceeding parallel to a criminal action. Defendant Hussein Amr, sole owner of U.S. Medical Supply, lnc., bilted Medicare for unnecessary power wheelchairs and their accessories, and also engaged in up coding and submitting inflated repair bills. Amr was found guilty in the parallel criminal case, and significant forfeiture of approximately $1 million was obtained. The civii division further obtained to disclose and properly account for reiated party transactions, Aurora submitted cost reports to the Medicare and Medicaid programs during the 1998 through 2000 cost years which failed to disclose Salem and the Network as related parties. Fraud against the Medicare and Medicaid programs reached nearly $1 million. United States ex rel. 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Hospital officials admitted they erred in the placement. Doctors allowed a patient to remain at the hospital's expensive and exclusive Two South unit -- which offered concierge service and a personal attendant- even though she was no longer receiving care. A doctor told inspectors in October that the patient, who began treatment 10 months earlier for depression and alcohol abuse, "was not acutely mentally ill" but "had the resources" to continue staying at the hospital in order to meet the terms of a court order. No translator was provided for a 79-year-oid Wetnamese-speaking woman during group sessions and numerous other assessments, meaning that the woman, who had hallucinations, had never been fully evaluated and went without treatment. "l stay in my room. haven't gone to any groups because don'l understand English," she told inspectors. Her son reported that at one point, a nurse called him by phone so he could "ask my mother why she was lying on the floor." Her case was documented by regulators after a surprise inspection of Las Encirias in late October, The inspection was done after the deaths of three patients in ive months and after the reported rape of the teenage patient. The Times reported those incidents last summer. inspectors also faulted the hospital for using pre-printed generic treatment pians for some patients and failing to document neurological testing in others. Regulators put Las Encinas ofhcials on notice that the facility was in danger of losing Medicaid and Medicare funding if the problems continued. ln a plan of correction tiled Dec. 11, Linda Parks, the hospital's chief executive. promised to correct the deticiencies. Among the steps she said had already been taken: "The facility posted a notice in their lobby informing the public that interpretive services will be arranged for patients free ot charge," Little progress Four days after Parks tiled her plan, govemment inspectors were back at the facility, which has 118 licensed beds. They found tirtle progress at the 29-acre campus, according to reports obtained last week by The Times. Despite Parks' assurances that the hospital had been offering tree translation services since late November. inspectors found an Arabic-speaking patient who had been without a translator for two weeks after his insurance company stopped paying for the service. By then, hospital records indicate, his doctor had described the mari, considered potentially homicidal and suicidal, as increasingly angry and upset. The patient could not easily express his feelings to therapists in English and was "becoming very paranoid with a lot ot persecutory ideas" and was "|os|ng a lot of hope," according to a doctor's note. inspectors who interviewed the doctor reported that no one had told him aoout the hospitai's promise to provide free translators. Las Enclnas' medical director later acknowledged that he had not told the staff about the change an the hospitals policy, according to the report. Mmm?- In addition, inspectors found that the hospital had continued to use pre-printed generic treatment plans despite being warned that it was a violation. Staffers were also still failing to document neurological testing. Steve Jennings, director of business development for the hospital, said late last week that Las Encinas "was found to bein full compliance" when inspectors returned Feb 17. Federal regulators, however, have not yet received the newest report from state inspectors. "Our top priority is to protect the health and safety of Medicare and Medicaid beneficiaries," said Jack Cheevers, Medicare and Medicaid Services spokesman, who also said that "most hospitals do come into compliance" when faced with the loss of federal funds. Parks declined to discuss patient care issues with The Times, citing patient confidentiality. But rn a statement, she defended the hospital. "lt is unfortunate that the many thousands of patients and their families who have been successfully treated at Las Encinas do not have an opportunity to tell their stories to the press," Parks wrote. "it is disappointing to realize that the only stories the media wishes io carry ignore the outstanding care we provide year after year." But the families of two men who died while in Las Encinas' care said they still have many questions about what went wrong ata hospital they believed would provide world-class treatment. Both young men wanted to be treated at Las Encinas because of its afhliation with Dr. Drew Pinsky, co-medical director of its chemical dependency unit, their families said. Pinsky, best-known for his nationally syndicated "Loveline" radio program and his reality TV show on Vi-lt, "Celebrity Rehab Vtith Dr. Drew," has been afiliated with the hospital for more than 20 years. He did not treat either man and did not respond to multiple requests for comment about the latest findings. Last summer, told The Times his heart was broken over the deaths there and defended the facility as an "excellent hospital." But he seemed to distance himself from the hospital, calling it a "bizarre misconception" that people associated him with the facility. At that time, he was the only physician whose picture was featured on the Las Encinas website. Currently, the hospitals home page features links to two news articles that refer to Pinsky's role at the hospital. His afhllation with Las Encinas is included in his biographical information that appears on Loveline's website and in numerous VH1 press releases. P|nsky's reputation drew Alex Clybum's family tothe private hospital, his mother said. Clyburn, a 23-year old Cel State Northridge student, sought substance abuse treatment at Las Encinas last April. .lust before he was admitted, Clyburn took a large dose ot OxyContin, a painkiller_ and Xanax, an anti-anxiety drug. After admission. hospital staffers gave him a mix of medications intended to ease his withdrawal. His fnothet, a nurse, later said she expressed concern to hospital staffers that the drugs would cause respiratory distress. She said a nurse assured her that they would check on her son through the night. Clybum was found dead in his roorn the next morning. we A mental health worker had falsitied patient records showing that Clybum was checked on every 15 minutes, investigators found. Logs tiled by the worker even reported Clyburn as sleeping just live minutes before a nurse discovered his body "cold stiff to touch with a blue face." an indication he had been dead for some time, The hospital said it tired the worker and promised to monitor patients undergoing detoxiication closely. What Clyburn's family did not know was that 16 months earlier, another young man had died after going unmonitored overnight by Las Encinas staff. Leo Grassini, 26, was found dead in his room tive days after he sought treatment for addiction at the hospital shortly after Thanksgiving 2006. Like Clybum, he had speciticaliy told his parents he wanted to go to Las Encinas. "He listened to 'Lovelirie' when he grew up, and Drew Pinsky worked there, and he felt that Drew Pinsky could help him with any problems he had," said his father, Lawrence Grassini, an attomey in the San Femando Valley. According to medical records, Leo Grassini had been prescribed narcotic medication intended to help wean him off opiates. i-le was later found lethargic and with depressed breathing and was rushed to the emergency room al San Gabriel Valley Medical Center, according to records. After emergency room doctors stabilized Grassini and sent him back to the private hospital. a Las Encinas doctor ordered that his vital signs be monitored "very closely for the next 24 hours Instead, his therapist found Grassini dead in his bed the next morning. His body was discovered only after he failed to show up tor a moming session. According to medical records, there were signs he had been dead for some time; his face and chest had tumed purple and were cool. Just as in Clyburn's later death, a hospital investigation found that a mental health worker had falsihed patient records to indicate that she had checked on him every 15 minutes. ln Grassinis case, hospital records showed that the worker even reported having checked on him after he had been found dead. in reality, government inspectors said, they found no evidence that anyone ever checked to see whether Grassini was breathing that night. ln a plan of correction tiled to the state nearly two years after Grassinis death and hve months after Clyburn's - hospital officials said they would place patients with "significant medicai risk" undergoing detoxification in a unit "specihc to their needs." The mental health worker accused offalsitying reoords in Grassinis case, the hospital reported, had been tired shortly after the incident. By then, Lawrence Grassini had long sinoe hired independent medical experts to review his son's medical records. All four experts identihed problems with the hospitals handling of his son's treatment and concluded in separate reports reviewed by The Times that Leo Grassinis death could have been avoided, "The failure to monitor Leo's viral signs is an egregious departure from basic standard of care and resulted in the death of this 26-year-old man," San Bernardino County chief medical examiner Frank Sheridan wrote in an oninior dated Oct. 27. 2007. Sheridan called tor an investigation as "definitely necessary so that others may be protected from such appalling care in the future 'l was shocked' After getting the expert opinions, Lawrence Grassini, who has not sued Las Encinas, had one of his law partners send letters to state and federai regulators in November 2007 and again in l\/larch 2008, urging them to investigate Las Encinas "so that further and future predictable deaths and injuries could be avoided." ln August, Grassini read the Times report of the deaths of Clybum and two other patients. "l was shocked, and mad, and so sad," he said. A week later, he received the results of a state investigation into his son's case, nearly 21 months after his son died, Govemment inspectors faulted Las Encinas for failing to monitor the young man, Of the worker who was supposed to be checking l.eo's vital signs, they reported: "There was no documentation or other evidence that she had been directly observed or had otheiwise demonstrated competency' in performing herjob. Until Arline Clybum was contacted by The Times, no one had told her about Grassinls death. In December, she and her husband sued Las Encinas for wrongful death and negligence. The hospital has not yet responded, her lawyer said. "When this happened in 2006, why didn't they initiate careful and appropriate vital signs checks?" Clybum asked. "Why are they against doing what they need to do to ensure Aurora Las Encinas Hospital warned by 'Feds Associated Press Posted: 08:33:53 PM PST Updated: 05:07:50 PM PST PASADENA - An upscale Southem Califomia hospital where four patients died and one was raped inthe last few years risks losing federal funding after inspectors learned of several recent escapes and suicide attempts, it was reported Saturday. ln the newest incidents at Pasadena's Aurora Las Encinas Hospital, a suicidal woman swallowed a battery and broken glass and another tried to hang herself with a hospital gown. Both survived. The tacility's latest troubles coincide with the confirmation this week that celebrity rehab specialist Dr. Drew Pinsky has severed tres with the tacitity after nearly two decades, a newspaper reported. Pinsky, who appears on radio's "L.oveLine" and Vi-l1`s "Sober House," did not respond to questions about why he left. He had been co-medical director ot the chemical dependency department. Aurora Las Encinas was warned it could lose funding from the Centers for Medicare and Medicaid Sennces. although most facilities are able to correct problems before this occurs, The waming is the second of its kind since tate 2008. Federai oficials are allowing state inspectors to enter the facility at any time to check on its compliance with regulations, Hospital officials could not be reached for comment. in a plan of correction prepared for federal ofticials, the hospital promised to monitor patients more closely. ln 2008, the hospital had three patients die in a nve-month period, That same year, it was reported that a patient entered the room ofa 14-year-old and raped her while employees slept. Aurora Las Encinas, which boasts of giving "the tinest care in the finest setting" on its V\/eb site and is popular with actors and rock stars, has charged as much as $1,600 a night for private rooms. Owned by Signature Healthcare Services, the hospital has recently undergone leadership changes, with the departure of its nursing director in recent weeks and chief executive ofncer last tall. Kids sexually assaulted at hospitals, reports say At least 18 cases of reported rape or sex abuse identified at some of the Chicago area's most prominent centers By David Jackson and Gary ll/larx, Tribune reporters 7:48 PM CDT, September 21, 2010 Two years after state authorities vowed to safeguard youths in hospitals from sexual assault, the Tribune identiied at least 1B cases of reported rape or sexual abuse at some ofthe Chicago area's most prominent facilities. Hospitals sometimes failed to properly supervise patients known to be dangerous or didn't notify police and state regulators ofthe attacks, government records show. "These hospitals' apparent indifference to our chiidren's safety is reprehensible and completely unacceptable," said Kendall Marlowe, spokesman for the Department of Children and Family Sen/ices, after leaming ofthe Tril;rune's nndings. "We accept responsibility for the children in our care and will not tolerate those who piace prohi over a vulnerable child's safety," The alleged victims - all under age 18 and some as young as 7 years old - were among society`s most defenseless citizens: youths with serious mental illness who were admitted in crisis to the taxpayer- iinanced institutions. ln the 18 cases since July 2008, all but four of the aiieged victims were wards of the state with traumatic histories of abuse and neglect, government records show. DCFS, tasked with protecting children from abuse, frequently conducted only cursory investigations, the Tribune found. The lilinois Department of Public Health, which licenses and inspects medical facilities, was able to tile reports and cite patient-safety deficiencies in only three of the cases. Both agencies said they are hamstrung by weak laws and inadequate resources. ln the end, no penaities were levied against the half>>dozen hospitals where the alleged sexual assautts took place. and not one oi the alleged perpetrators was arrested or prosecuted, the government records and interviews show. At Chicago Lakeshore Hospital on the North Side last year, three male patients allegedly sneaked into the room of a 15-year-old girl at night. She told police that she tried to push away one of the boys, but he grabbed her by her hair and raped her. When hospital entered the room, the boys refused to leave and fought staff, with one of them kicking a 60-year~old nurse, according to a court memo, But a hospital employee told police that "taking into consideration victirn's current mental state this is not bona tide incident," The Tribune identified three other reports alleging that youths had been sexually assaulted or abused at Lakeshore since July 2008 ln one case, state health inspectors cited Lakeshore after an 1i>>year- old boy alleged that two male patients sodomized him in a bathroom that should have been locked and supervised by hospital staff. inspectors said the hospital failed to document that staff had made required 15-minute checks on the two alleged assailants, one of whom had been admitted with "special observations orders for assault precautions." None of the hospitals would discuss specihc cases with the Tribune because of medical privacy laws, but a statement from Lakeshore said it has responded to assault reports by making improvements in "patient safety and positive clinical outcomes." Lakeshore added that its patients "often behave in unpredictable ways" but said the hospital "believes it does a betterjob" of reporting assault allegations to DCFS and other authorities "than any other facility in |llinois_" Experts say sexual assaults of youths in hospitals are generally uhderreported - but the devastating events often reveal systemic shortfalls in staff levels or in monitoring and treatment practices. Because many young patients are admitted to hospitals with histories of sexual and physical trauma, "both exploitive behavior and being exploited are entirely predictable. One of the fundamental responsibilities of any clinical program is to keep the children sate," said Clarence Sundram, the former chain-nan of New York states Commission on Quality of Care for the Mentally Disabled. Overall, the 18 cases uncovered by the newspaper involved tive reported rapes. There were nine reports of sexual abuse such as molestation; in two of those, the alleged victims were 7 years old. In the remaining tour cases, hospital or govemment authorities tabeled the sex "consensual" - although that is a serious violation of standard clinical practice and DCFS policies. and even though thejuveniles involved were as young as 12, records show. "The tact that they are even able to have what some term 'consensual sex' is just abhorrent, because it says the system failed to keep kids sate and make them better," said Cook County Public Guardian Robert Harris. ln addition to the 18 cases the Tribune identined, records show two alleged rapes of mentally disabled DCFS wards who were 18 and 20 years old. The newspaper found several other assautt reports that it did not count because the alleged victims gave contradictory statements, remnted, or did not appear credibie based on police or other government documents. ln July 2008, after the Tribune exposed a string of reported sexual attacks of young wards at west suburban Riveredge hospital, DCFS launched several reforms: the agency tightened reporting of assault allegations, hired two additional hospital safety monitors and assigned a team of University of lliinois at Chicago experts to investigate conditions at the facilities The team is now completing an examination of stating levels and training as well as the alleged sexual assaults there. "We oontinue to press this issue in every way we can," DCFS spokesman ll/lariowe said, But Marlowe added that DCFS would welcome new legislation to give the agency and the health department the staff and legal authority they need "to ensure safe, quality care in hospitals." The Tribune pieced together the 18 recent accounts using police reports, public health records, DCFS documents and court tires, ln some cases, the records were incomplete and hospital staff cast doubt onthe veracity of the young patients. However, Marlowe said, the hospitals sometimes offered DCFS investigators "fronts, tabricatlons and flat-out lies." The cases indicate breakdowns at every step of the investigative process. ln seven ofthe nine alleged sexual abuse cases, hospitals did not inform police ofthe alleged crimes, records show. tn some cases when police were called, the oflicers were apparently impeded by medical privacy laws from learning the names of all the parties or witnesses involved. DCFS and the health department, which also share responsibility tor investigating the sexual assault allegations, don't get police reports and rarely coordinate their investigations with each other, records and interviews show. The DCFS investigations into these incidents failed to find neglect or lack of supervision by hospital staff In one example, police were called to Hartgrove Hospital on the oity's West Side when a iuveniie patient alleged he was punched and forced to perform oral sex on a male patient, then raped when he tried to resist. The alleged victim was hospitalized with abrasions consistent with rape, a police report said. brief investigative report didnt mention a rape allegation or note the alieged abrasions - but it extensively quoted a l-lartgrove worker who said "he makes rounds every 15 minutes in the room of each patient to check to see if they are all right. He slate(s) that patient safety is his priority." The neglect allegation was ruled "unfounded" ln a written statement, l-iartgrove said it "takes the safety and well- being of its patients very seriously" and "complies with the reporting requirements mandated by the state agencies and all regulatory entities," Another problem crops up because state laws enable DCFS to open neglect investigations only on individual hospital employees - and not on the hospitals or the top administrators who sei oolicy and staffing levels, according to Marlowe, As a result, cases are "unfounded" even when DCFS investigators conclude the hospitals were negligent, In another example from Hartgrove, a 13-year>>old male patient performed oral sex on a 15-year-old DCFS ward in a day room crowded with roughly 14 other youths and only one nospitat employee to monitor them, records show. The worker said he was distracted by trying to defuse a "conflict" among other youths in the room. A DCFS investigation determined that "the level of supervision in the day room was inadequate" but concluded that "the institute Harlgrove is the perpetrator' of negligence and not the lone employee, As a result, the case was "unfounded" and closed with no disciplinary aelionl Unlike DCFS, the health department does have the authority to revoke a facility's license. But the health department says it lacks the authority and inspection staff to investigate all but a few ofthe alleged child sexual assaults. And ii does not have the legal ability to levy fines on hospitals when it does cite safety infractions. Health department spokeswoman ll/lelaney Arnold conceded that her agency is "extremely limited under current law in enforcement action against hospitals that violate regulations." Since a new state law took elteot in January, hospitals have been required to notify the health department of assault or abuse allegations, But, Arnold said, none has done so. ln the past legislative session, the department proposed establishing a S30 bed fee from hospitals to hire additional inspectors, but the Dill was killed by opposition from Republican lawmakers andthe powerful hospital industry. said bill wsponsor Rep. Mary Flowers, D-Chicago. di4aolfson@tribune.com Metro Times METRO TIMES 'l/8!2003 A tale et two hospitais The of a two-part series. sv ous? euvsrre 9251 Pit "What happened there is scandalous," said former board member ll/iel Ravitz. "l~le wanted me to convince the Ganeshes to seli their shares to hirn. And it would do that, he would pay me." Carroil testified. Pfescri inn .TWO hospitals 1 undone docton i -sms' i "ty _rgfhiv . we if tat" 5; .i A 1 _f Esgiri fy. oe' A -#1452 The pitch was impressive. With an otter on the table to purchase the Chicago Lakeshore hospital, the State ot Illinois required a public hearing as part of its approval process, allowing mental health advocates and residents to question and evaluate the potential buyer. Which is why, in August of 2001, three top executives from the Saiem Service Co. oi California ventured to the Windy City, Their mission: assure folks that the company woutct provide quality care and, as a good corporate citizen, contribute to the weli-being oi the entire community, Salem's vice president of operations, P. Blair Siam. handled most of the presentation, taking care to iimn the character and qualifications ot the man engineering the whole deal - ametro Detroit and businessman named Soon K. Kim. iew years back he decided to retire," began Siam, "li you know Dr. Kim. retirement generally did not work for him. He's too active. And he came out of retirement a few months later for two reasons. One, i think he was bored. But two, he had a heart for what was happening in behavioral health care. And in the Detroit area at that time, it was falling apart. The main hospital had gone into bankruptcy. And he felt that unless someone stepped to the plate, that knew what good care was, that xnew the business, and was willing to step in and take some responsibility and not be greedy, that, as a high likelihood, they would continue to go down. "He did step in ar that time and purchased the facility, this iirstiacility in Detroit in the mid-'90s out ot bankruptcy, and has been very successful in turning it around, and it's going strong to this day." Aithough never mentioned by name, the Detroit facility referred to as the Aurora mental hospital on the city's west side. Stern hit the mark when he talked about Kim stepping in to retrieve from bankruptcy the one-time pride of Detroifs mental health network; it's difficult to overstate Aurora's importance to the community. Established as a nonprofit corporation in the 19803, Aurora's primary mission became the delivery of care to troubled children and teens, Consisting oi two buildings with a total of 140 beds, the hospital treated adults as well, including mentally ill inmates transterred iron" the county jail There were, however. a few details not covered in presentation. As he and his colleagues were touting Kim's virtues in Chicago, Aurora was far from "going strong." Eesieged by government health care regulators and facinc dire financial straits. it circled a tasttrack to oblivion in August"200t. Within six months its lifeblood contract with the local mental heath Page 1 F7 Metro Times - a; as - :ff Dr. Soon K. Kim r) in court. fighting over Greater Detroit Hospital. c, . 2; 3* . aft; 22. i 9 r, tf. ?32411 The widow of Orekonde Ganesh, Daksha ll). and Linda Carroll battled Kim in court. 10/20/10 9:51 PM board would be canceled and its doors closed, leaving Detroit without a mental hospital. The mentally ill who relied upon Aurora for two decades were forced to scramble in search of care outside Wayne County, further burclening already troubled lives. As for Kim himself, a Metro Times investigation found evidence of a man much different from Stains depiction of a bored retiree motivated by altruisrn. Instead. his critics, financial records and court documents portray a shrewd and rapacious businessman. According to our analysis, a web of tor-profit companies affiliated with Kim collected at least $23 million from the hospital in a span of four years. That windfall came at a heavy cost, say critics, who point to government reports that show patients at Aurora suffered from inadequate care while an undermanned staff struggled to do its jcc. An attorney for Kim disputes our financial analysis, saying the figure "sounds inflated." The doctor defends his business dealings, saying his for-profit companies provided services at or below market rates, and that an independent board running the nonprofit hospital approved the contracts. Moreover, says Kim, Autores fate was part of a pattern. "Media reports over the past few years have detailed the closure, and pending closure, of several mental health facilities/hospital unite," asserts Kim, who declined requests to be interviewed for this article burdid respond to written questions. "importantly most, it not all, of these facilities serviced a predominantly Medicaid population. Cuts in Medicaid funding, among other factors. have played a significant role in the closure of hospitals throughout this county, state and country." That is indisputable There is also the matter of $4 million Aurora officials claim is owed tnem by the Detroit-Wayne County Community Mental Health Agency. William Stone, the former chair of Aurora's board of directors. maintains that the county/'s refusal to pay that debt is uldmately what led to the hospitals downfall. The county agency claims that. rather than owing the hospital money, Aurora owes it more than $1 million. That issue is being fought out in Wayne County Circuit Court. But critics of Kim claim Aurora struggled under an additional burden. "Dr Kim milked Aurora for all he could," says Mel Fiavitz, a tormer Detroit city councilman who served onthe Aurora board for more than a year before resigning in protest. "What happened there is scandalous." lr was also, in key respects, a repeat performance. That'-s another piece of information absent from Starn's presentation: Aurora vvasn't the first Detroit hospital to sink while a company of Kimls manned the helm. And it wasnt the first tc spark accusations that avarioe on the part of Kim resulted in a shuttered hospital and lost jobs. Before Aurora came Greater Detroit Hospital, which closed in 2000. Kim contends that the blame for that hospitals failure. tike Aurora's, belongs to cuts in Medicaid funding and the failure of Wayne County to pay its bills. But, in a bitter lawsuit that has dragged on for more than four years, a former business partner of Kirn's claims that he drained Greater Detroit to financially benefit Aurora and other companies he controlled, and that those actions financially crippled greater Detroit. Partnership splintered At 60, Dr. Soon K. Kim has lived the American dream. The immigrant from South Korea and his wife, Bouh. who's also a have amassed a net worth of S40 million. according to an unaudited financial statement submitted to Illinois regulators, `l`t1ere's a Si million home in Bloomfield Hills. and a farm in Salem Township worth 366.2 million. There's a second home. valued at $1.3 million. in the exclusive seaside community of Dana Point in Southern Kirn's share in seven lui/ .metrotifnescom p?id=4462 Page 2 of 7 Times 10/20/10 9:51 PM health-care companies is worth $18 million, according to his financial statement. Theres another $7.5 million in cash and investments, and millions more in retirement accounts. Born and educated in Seoul. he immigrated to the United States in 1966 at the age of 24, arriving here with a medical degree, boundless energy and a head for business. After sewing an internship in Buffalo, he moved to the Detroit area and began a residency in at Wayne County General Hospital. He served at various local hospitals, rising into management before ?enturinlg out on his own. By the early 19905, he owned a string of outpatient clinics operated under the name Evergreen ounseiing. ln 1994, he bought his first hospital. Working with a fellow physician named Orekonde Ganesh, he purchased the bankrupt North Detroit General Hospital and an adjacent medical office complex on the border of Hamtramck for $2.2 million. It was a risky venture. Southeast Michigan had an abundance of hospital beds at the time, and some saw the attempt to onng an empty facility back on line as foolish. But Kim and Ganesh, with the help of administrator Linda Carroll, had a plan. First they created a nonprofit corporation they called Greater Detroit Hospital. The nonprofit, on paper at least, had control over running the reborn facility. With Kim, Ganesh and Carroll serving as the nonprofits initial board members, it leased the hospital and its equipment from Greater Detroit Hospital-Medical Centers, a new for-profit company they iointly owned. According to court records, Kim controlled 50 percent of the corporation, Ganesh, 43 percent and Carroll, 7 percent. A second company with the same ownership structure was created to provide the hospitals management team. According to the contract. that second company, First Sterling Management, would furnish a chief executive officer, financial officer and other top personnel responsible for day-to-day operations and long~term planning. Carroll. a longtime family friend and business associate of Gans-sn's, was selected to be the CEO. Once everything was put in place, Ganesh and Kim recruited board members and stepped down from the board. The new trustees then ratified Carroll as the hospitals CEO. Restarting a bankrupt hospital proved every bit as daunting as the skeptics predicted. Because of the prior bankruptcy, credit was impossibie to come by. Medical certification had to be acquired anew. Staff needed to be hired. Cash was chronically short, in retrospect, Kim would admit the venture was underfunded from the outset. But Carroll persevered, and business began to build. According to her, she kept in constant touch with Kim, talking with him several times each day and sending him financial reports weekly. By 1997, according to an internal Revenue Service filing, the 225-bed hospital had revenue of more than SB million per year. While Carroll handled finances and bureaucratic matters, Ganesh concentrated on medical operations. Kirn's role was to build up services. To that end, a company named Promed Management, which had Kim as its president. signed a contract with Greater Detroit Hospital Medical Centers in April 1994 to provide a "partial hospitalization" program tor mentally ill patients at Greater Detroit. More intense than outpatient services but less costly that full hospital stays, such programs provide daylong treatment over short periods, Along with continuing to run the Evergreen Counseling Centers, Kim and at group of investors paid a reported $5.5 million for another hospital - a facility in Warren known then as the Carlyle Center tor Mental Health. it too had gone into bankruptcy. in addition to serving the general public, part of the facility. renamed Arborview, was leased to the Childrens Home of Detroit. a charity that provides an array of services to troubled children. Power struggle The partnership between Kim and Ganesh came to an abrupt end in July 1995 when Ganesh died in an accident. He drowned after his car plunged into a pond. He left a widow and three daughters Carroll refused repeated requests to be interviewed for this story, saying a confidentiality agreement and an ongoing lawsuit she has filed against Kim prohibit her from talking. The Ganesh family, which also sued Kim in a fight over how assets owned bythe two doctors would be divided, declined to be interviewed as well. But the accounts of what played out at Greater Detroit Hospital unfold in voluminous depositions taken as part of those lawsuits. According to sworn deposition, this is what happened following Ganesh's death: Kim wasted no time moving to fill the void created by his partner's demise. At the funeral home. while the viewing was under way, Kim pulled Carroll aside and demanded that he replace Ganesh as president of Greater Detroit Hospital-Medical Centers, the for-profit company leasing the hospital to the nonprofit. But assuming the presidency of the company wasnt enough; he wanted control of both the hospital and First Sterling, the foi'>> profit management company, and to do that he needed more than 50 percent of the stock. Page of 7 Times 9151 PM ln September 1997, Kim issued a letter ol intent stating he would buy out his partners' interest in the hospital and adiacent office complex, known as Carpenter Plaza, ior $400,000. Because of her long triendship with Ganesh, Carroll was designated by his tamily to be the estates personal representative. She insisted on obtaining an appraisal of all the property before considering any ofter. Kim, seeking to gain her assistance in persuading the family to sell, attempted to "bribe" her, she testihed. "Dr Kim demanded that sell my stock to him or use my influence to induce the Ganeshes to sell stock to him. When refused, Dr. Kim threatened to bankrupt the hospital and run them out." Kim says that accusation is "a complete and total fabrication." lt so, it is well-embellished. "He wanted to buy them out and he wanted to buy itat a low price without an appraisal." Carroll testified. "He wanted me to convince the Ganeshes to sell their shares to him. And it would do that. he would pay me. One number for sure was 5 percent of all the laboratory work that came through his Salem organization." "Do you have any idea, based on all the depositions we've been through, how much money were talking about?" Carroll asked, addressing the attorney who had been questioning her for hours. She answered her own question: "Probably millions of dollars, And lor someone tc say no to that, which did. and protect the widow and three kids, which was the right thing to dc. and did that. Do you see why have such a bad taste in my mouth about what went on at this hospital?" By the fall of 1997, more than control ot the company was shredding the business relationship between Kim and Carroll. She claims that's when Kim began plundering Greater Detroit to the benefit ot Aurora. Aurora rises In the spring of 1997, a for~prolit limited liability partnership, called Michigan Health Care Network and controlled by Kim purchased the Aurora mental hospital in Detroit out of bankruptcy for $4.2 million to keep it operating. Almost immediately, Kim set up a deal that was supposed to benefit both the new acquisition and Greater Detroit Hospital. Secause of a state iaw in existence at the time, Aurora needed to be affiliated with a hospital that performed medical and surgical procedures. in addition, Greater Detroit would lease 40 beds at Aurora at a rate of $56,000 per month. Carroll testilied that Kim promised her that the income associated with those beds would generate profits of 15 percent to 25 percent tor Greater Detroit. Also. Aurora and Arborview began using Greater Detrolt's pharmacy, paying a 15 percent markup in return tor being able to acquire the drugs without having to pay up front, according to Carroll. Aurora and Arborvlew were also cash- strapped and having credit problems because of their respective bankruptcies. But the deals didn't pan out. By October 1997, Greater Detroit was in financial crisis. According to court documents filed by Carroll, a Medicare audit oi the Promed program tound mayor problems. ln essence, the government alleged that some patients who could have been controlied with medication and did not require acute care were needlessly being admitted to Greater Detroit, according to Canoll's deposition. Another former hospital administrator agreed, stating in a deposition that the deal had indeed come under the scrutiny ol regulators who alleged that required documentation showing the need tor hospitalization was missing, and that the length of time many patients were staying in the program couldn't be justified. An investigator in Detroits Medicare office also confirmed that a probe had been conducted. but relused to provide details. According to Carroll, the government demanded repayment of $786,000. She negotiated the amount down to less than $300,000. Taxing problems Even more pressing was an issue with the Internal Revenue Service. Court documents indicate the demanded bacl: payroll taxes totaling at least $600,000. The state and City of Detroit were also owed payroll taxes. On Oct, 17, 1997, Carroll told the board about the tax situation. She also presented a plan. According to minutes from the meeting, Carroli calcuiated that Aurora and Arborview owed Greater Detroit more than $500,000 Collecting that money would enable it to pay most ot the debt. ln addition. the hospital was expecting an infusion of cash because oi new programs coming on line, with as much as $400000 due within months. But Carroll never gotthe chance to put her plan into action. On Oct. 23, Kim summoned her to a rneetino at Aurora and told her she was tired. Locks were changed at Greater Detroit; when she showed up there, armed security guards tried to force her out. When she refused to leave. the police were summoned. Page 4 of Mem Timer Greater D_etroit's board of directors sided with Carroll. They maintained she was their employee. and that Kim, as president of First Sterling Management, had no authority to fire her. Board President Timmiah Ramesh responded to Kim's firing ot Carroll by issuing her a letter saying the board was "pleased" with her periormence and wanted her to remain as CEO. Kim ignored their protests. They, in turn, retused to cooperate with Kim and the new executive otticer he selected to succeed Carroll. The board filed a lawsuit to regain control of the hospital. Jerome Moore, the attorney who represented that first board, says he has no doubt that Kim acted improperly in tiring Carroll. "li was illegal." he says in response to a question about the lawsuits basis. "lt should not have happened." But the lack ot money to fight, coupled with the deatn of two board members and the steady decline in the hospita?'s viability, eroded motivation to pursue the case. A replacement board was eventually installed, "Our purpose was to try and preserve the hospital," says Moore. "But at a certain point, it became apparent that wasn't going to be possible." The Ganesh family, which along with Carroll still owned 50 percent ot 'First Sterling. also went on record supporting Carroll. But Kim prevailed. He appointed a new CEO, and brought in employees irom his other companies to serve as olticers ot the nonprofit Greater Detroit. Despite the obligations, Kim directed that $300,000 be paid from Greater Detroit to Aurora within two months ot Carroll's tiring. she testified. She also alleged that Kim took the employees and inventory from Greater Detroifs pharmacy and, without compensation to the hospital, used them to create a tor-profit enterprise. Salem Hospital Pharmaceutical Co. (Salem Hospital Pharmacy and Salem Transportation were subsidiaries ot a new management company, Salem Services. controlled by Kim.) Kim denies the allegation. According to Carroll, Greater Detroit, which had owned the pharmacy, suddenly was paying a 15 percent markup tor drugs. Kim then attempted to squeeze Greater Detroit even further. Immediately tollowing Carroll's tiring. he demanded payment of rent and management fees he claimed were owed. ln a letter to the board, he stated that Greater Detroit Center was owed $45 million in rent, and that First Sterling Management was due $1 million. "Kim made the demands to try to create a state oi panic and crisis at the hospital so he could take over control," Carroll alleged. Skeletal company The $1 million bill from First Sterling is particularly interesting, During his deposition. Kim admitted that First Sterling had no offices. no phone, no stationery, no employees. Greater Detroit was its only client, According to the deal First Sterling inked with Greater Detroit, the management company would provide a CEO, CFO, a risk analyst and a host ot other management services. But, according to Carroll, during her tenure there was never a financial oiticer or risl< analyst, and her CEO salary was paid by the hospital, not First Sterling. Asked during a deposition whether the obiigationsvoutlined tor First Sterling in its contract were tultilled and the services actualiy provided, Kim, the companys president, replied. "l cannot say exactly whether it was provided or not," Likewise, Laura Sanders, an attorney employed by Kim as an assistant in his various businesses. testified during a deposition that, to her knowledge, the only services provided by First Sterling involved supplying a CEO. Asked to justiiy the $1 million management bill, Kim responded, don't know the specifics." According to Carroll, First Sterling was never paid because Medicare had "disallowed" the management companys charges, saying no work had been performed. told Kim Greater Detroit Hosoitai was not going to pay because First Sterling Management didn't provide the services," Carroll testified. Meeting minutes state that Greater Detroifs new board members asked whether there would be any ouestlons about their legitimacy. James Brenner, an attorney who represented the nonprofit corporation yet served as Kims personal attorney wher he was sued by its board, responded: "lt would appear that the purported board never were actually appointed." Page 5 ot' 7 Me Times 9:5 in any case, he added. the old trustees "have abandoned the role of board members by refusing to meet." The Ftev. Jim Holley of Detroifs Little Rock Baptist Church was selected chairman ot the new board. A year iater, as Greater Detroit was rapidlytailing, the replacement board cried foul regarding the relationship between Greater Detroit and Aurora. in a letter to the Aurora board dated lvlarch 18, 1999, Holley wrote that has been released to Aurora" without justifying documentation, in addition, Greater Detroit had provided Aurora more than $11 million in "in-kind service." "Pass through of dollars," declared Holley, "will discontinue." According to Carroli, the motivation for Kim to tunnel money into Aurora was a management contract that. in part. tied the for- profit Salem Services' tees to a percentage of nonprofit Auroras revenue, At least tout other for-profit companies affiliated with relied on income trom Aurora as well. Eventually, Aurora no longer needed Greater Detroit. Because oi a change in state law, it was no longer necessary tor hospitals to be affiliated with facilities providing medical and surgical procedures. By late 1999, Greater Detroit was on its deathbed, Its staff had been reduced from a high oi nearly 300 to a skeleton crew ot 20. At least two offers were made to purchase it, but according to Holley, no deal could be struck because of ongoing irrigation between Kim, Carroli and the Ganeshes, who were fighting over ownership ot the property and responsibility tor paying back taxes, "Our concern was to try and save that tacility, and keep it operating as a hospital, because it performed a needed sen/ice tor the people ot that community," says l~loliey_ "But by the time our board was established, it was all downhill. By that point, there wasn't much anyone could have done to save it." Another view Kim cautions that sworn deposition testimony from Carroll. his iormer business partner, should be kept in perspective. "We hope that in reading Ms. Carroliks deposidon, you considered the that Ms. Carroll was in the midst of litigation she hoped to financially benetit from," he wrote in response to questions from l\/letro Times, Court documents provide a variety ot reasons Kim gave iustitying Carrol|'s tiring. in a sworn affidavit provided by Kim a month after the dismissal, he claims to have been completely unaware of nonpayment ot payroll taxes, l-le said he learned of the situation when he inquired about a $75,000 payment due Aurora. "When I asked it/ls. Carroll about the payment she said she could not pay Aurora because she had just sent 3100.000 to the IRS for payroll taxes. This aroused my suspicions. On further investigation, found that Greater Detroit Hospital aotualty owed hundreds ot thousands of dollars more in payroll taxes than Ms. Carroll had led me to believe." An attorney tor Kim offered the same explanation to the new Greater Detroit board. Kim also claimed to have become concerned that Carroli had a conflict ot interest - she was working for Greater Detroit while owning stock in First Sterling, "ln my opinion, to avoid related party transactions. the CEO of a nonprofit corporation should not hold any stock in a profit- rnaking corporation he wrote to ner two weeks before ner dismissal - and more than two years after he helped create the very situation he was complaining ot. Kim also accused Carroli ot devoting an inordinate amount ot time to issues related to the Ganesh estate, detracting from ner Greater Detroit obtigations. There were also allegations that Carroll was an incompetent administrator. and questions aoout her honesty were raised. Those allegations led her to add slander and libel to her lawsuit against Kim and his companies, Ultimately. Kim testified: "l fired her because thought that as president lot First Sterling] could tire her without any cause." Asked during a deposition to point cut where in the agreement between First Sterling and Greater Detroit that power is granted, he could not. But, Kim protested, he was just a layman, Asking him to interpret a legal contract was untair. Under Questioning during a deposition, Sanders, the attorney who served as Kit?n's right-hand assistant, agreed that Kim was extremely intelligent, extremely logicai and very detail-oriented. But the person reflected in Kim's deposition sounds markedly ditterent. He dtsotayed a porous memory, a handsott IPM Page 6 of 7 M?lf? TMS iorzu/10 9:51 PM management style and an incomplete command of English. For example, when asked about his role at Greater Detroit Hospital, Kim responded: "l was not involved in nothing, period. at Greater Detroit Hospital." Asked when the hospitals board was created. Kim replied, "l have no idea." Pressed to say whether Carroll was an employee of First Sterling or an independent contractor, Kim stated, "l don't know what understand." Typical of Kim's deposition testimony was this exchange between him and William Dohreff, the lawyer lor Carroll. Q: Dr. Kim, were you supervising the Were you? A: Supervising? Q: Yes. A: don't understand. just as part oi management contract First Sterling Corporation has ooligation to provide qualified professional manager who work as chief executive officer for the nonprofit corporation. dont supervise none because we have different expertise but that person would expect to function as in chief executive officer which whatever that function is to make assure that hospital corporation runs without getting in trouble, QS Were you supervising her, sir? l'm not supervising her. Carrolls difficulty during her deposition was ol a different sort. Transcripts of her tesnmony make it seem obvious she had troubie keeping her emotions from spilling over at times, She testified to sometimes iorgoing pay so that checks to hospital staff wouldnt bounce, and to purchasing equipment with a personal credit card when hospital accounts were running low She was particularly fervent when discussing the issue of greed with Kim attorney James Brenner. '"l'hat's why were still here today," she said. "And diets why that hospitals overgrown with weeds and no patients are being seen. You should be ashamed, and Dr. Kim. Greed, Mr. Brenner. Greed." Last year, a part of that lawsuit was settled, with Kim agreeing to pay the more than $600,000. receiving control of the hospital and medical building in return. Kim maintains that Greater' Detroit proved to be a losing proposition. Kim says he and Salem "have lost a iot oi money because of mismanagement by others." That may be true. But if Linda Carroll's allegations are correct, while Greater Detroit was losing money, Kim and his companies reaped a fortune at Aurora. "He benefited directly from money paid to Aurora," alleged Carroll, "and he left Greater Detroit with no means to stay afloat." The hospital shut its doors permanently early in 2000. Because ot the length ot time it's been idle, the hospitals state license was formally revoked last month. "l took at that hospitai standing there empty," says the Rev. Holley. "and rust see so much waste." Next week: Dr. Kim establishes a web of companies that reap millions of doltars while patient care suffers. an undermanned staff struggles. and another hospital shuts its doors. Check out Dr, Kim and his associates web of nonprofit and for-profit companies. Who sits on the board of directors for Dr. Kim's nonprofit corporation? Read the second installment of this controversial cover story. (C) 201 Metro Times .metrotrmesxom printStory.asp?id Page 7 of 7 _'nv Requiem for a ward BY CURT GUYETTE Dr. Kim deserves an award for what he did," told Metro Times41511Dr. Soon K. Kim, in court for a case involving ownership of his hospitals;ie'ff said Stone. "l'll sue anybody who says had a conflict of interest," Stone Ed|'tor's note: ln Part I of this series, Metro Times relied on sworn testimony to report allegations that, after buying Greater Detroit Hosp/tal with a partner in 7994, Du Soon K. Kim threatened to bankrupt the facility if he wasnt able to gain full control of it. Depositions taken In iiugation against Kim also alleged that, after he bought the Aurora mental hospital on Detroits west side, Kim began siphoning money from Greater Detroit into Aurora, propping up his new acquisition ta the detriment ofthe Hrst. ln a letter to Metro Times, an attorney representing Kim said Part i contained unspecified ialse statements and is libelous. He demanded that the entire article be retracted. Metro Times declines to do so. ln Part ll, some former members ot Aurora's board accuse Kim of using a network of companies under control to reap millions of dollars from a nonprotit corporation he created. At the same time, allege his critics, patients at Aurora were subjected to substandard care while an undermanned hospital staff struggled to do its job. Mel Ravitz sounded the alarm loud and long. As a member ct Aurora Healthcare's board of directors, the former Detroit city councilman began issuing a series of increasingly urgent protests In January 1999. The nonprofit mental hospital needed to curtail its relationship with and businessman Soon K. Kim, Havitz warned. Otherwise, its future would be in certain jeopardy. None oi his fellow board members paid heed. Even now, with the hospital empty for more than a year, there are former board members who depict Flavitz as a curmudgecn and a crank. "Mel Flavitz was the worst thing that ever happened to my board," said William Stone, chairman ofthe Aurora board for nearly five years. "You can discount everything he has to say." What Flavitz has continued to say is this: So much money flowed from Aurora into Klm's for-profit companies, the nonprofit hospital could not survive. The llow ot cash was considerable indeed. A Metro Times analysis of the hospitals filings with the internal Revenue Service and other documents found that for-profit companies affiliated with Kim were paid at least $23 million by Aurora over the span of four years. A representative for Kim disputed that figure, saying it is "intlated." Page 1 of 9 Metro Times it Tift I ii gf-eq if "ww" 5/use coseiuwr 'Jifxf _ve-f 1 1974 1981 that the erm" of a 'd I 10/201 10 9:54 PM Moreover, Kim said he bears no responsibility for Aurora's demise. ln general, he blames government agencies for policies that led to the hospitals closure. Stone, too, faults the government. He is critical of tormer Gov. John Engler's welldocumented neglect of Michigan's mental health system. He is even more condemnatory ofthe Detroit-Wayne County Community Mental Health Agency, which Stone claims crippled Aurora by failing to pay the hospital $4 million it allegedly owed the facility. instead of being criticized by the likes of Flavitz, said Stone Kim is due kudos for his attempts to keep Aurora open and serving the mentally ill. "Dr. Kim deserves an award for what he did," said Stone, who also disapproved of the way some critics depicted Kim in Part of this series. "ln my opinion, all these people said things that aren't true just to get back at him," said Stone. "Something nice should be said about him. He's not a bad guy," Somewhere between the polar opposites of Fiavilz and Stone is anotherformer Aurora board member, George Gaines Jr. Gaines agreed with Stone that the local mental health agency's failure to pay its bills played a part ln Aurore's downfall. But, admitted Gaines, he also realizes now that it was a mistake to have ignored Revitz. Aurora's beginnings Prom its inception Mei Ravitz harbored a keen int est in Aurora. lt was toward the end of his tenure as director of the Detroit-Wayne County Community Mental Health Board, which he headed from - ea to uid a nonprofit mental hospital in Detroit took root. The board began working with Michigan Health Care, a nonpront corporation, to build the facility, and then helped fund its operation. Ftavitz continued to keep a protective on the hospital as he took a seat on the Detroit City Council Consisting of two buildin 'th ,wi a a 0 140 beds, the hospital established what Ravitz describes as an excellent reputation over the years. Part of the facility was dedicated to serving children and teens. The hospital, located on the oity's near west side at 3737 Lawton a so provided care to adults, including mentally ill inmates transferred from the Wayne County Jail. The vast majority of patients were poor and without insurance. "lt was," said Havitz, "a vital facility." About that there is little doubt. All con Wayne County. oerned describe Aurora as a critical link in the mental health system serving Detroit and Built in two phases during the 1980s, Aurora became a subsidiary of a larger nonprofit organization called Michigan Health Care (MHC). During the late '80s MHC went on an ex ansion spree, accumulating debt exceeding $200 million. ln 1997, with the param company declaring bankruptcy, Aurora, along with the rest of MHC, went on the sales block. That's when a for-profit limited liability corporation created by Kim stepped into the breach. There is no denying Kim's skills as a businessman. He arrived in the United States as an immigrant from South Korea in 1966. Since then, he and his wife, Bouh, who is also a have amassed the sort of wealth most people only dream of According to an unaudited financ` ia atement obtained by Metro Times, Kim estimates his holdings to be worth $40 million. There's a $1 million home in Bloomfield Hills and a $6.2 million farm in Salem Township. The couple also owns a $1.3 million home in the swank oceanside community of Dana Point Calif Various business interests are valued at $18 million. Chief among those businesses is Michigan Mental Healthcare' Network. With a net value of $10 million, that company played a prominent role in events at Aurora. Supporters oi Kim, such as attorney Thomas Sweeney, hail him as a savior. |ttp:/ Page 2 of 9 Metro Times INDI 10/20/10 9:54 PM "There was a guy who wanted to buy it (Aurora) and turn it into a truck driving school," notes Sweeney, whom Kim selected to be secretary of the Aurora board. Sweeney works for the prestigious Clark Hill law firm and served as the registered agent for several ol Kim's businesses - including two that did business with Greater Detroit Hospital - beginning in 1994, according to records on file with the Michigan Department of Consumer and lndustry Services. While Sweeney served as Aurora'e secretary, another Clark Hill lawyer served as Kim's personal attorney in a lawsuit filed a gain lm by the board of directors at Greater Detroit Hospital and the estate of a former business partner. While it is true a limited liability for~profit corporation - the hospital itself was on relatively solid financial footing, according to several sources. that Aurora was purchased out of bankruptcy - for $4 2 million by Michigan Mental Healthcare Network Erv?n Johnson, a longtime employee who ran Aurora's outpatient clinics before becoming its chief executive officer in 1999, sai the 1 sa in 997 was greeted with optimism. Freed from the burden of helping to carry the parent company's debt, it locked as though the facility "wouid be in pretty good shape," he said. ;;We were three~quarters full when sold," recalled Johnson. "And we were a primary force for mental health care in Wayne cunty." Johnson said staff at Aurora prided themselves on treating "the chronic patients nobody else wanted. We never rejected anybody." Kim created the nonprofit Aurora Healthcare to oversee the facility, and, according to Ravltz, before an independent board of directors was installed, saw to it that the nonprofit entered into agreements with two of his for-profit companies. Kim, who declined tc be entered into by an "independent" board. When pressed, he subsequently conceded that the formal board ratified the contracts at a later date after business had already commenced. interviewed by Metro Times but did respond to written questions first indicated the contracts were Aurora began leasing the hospital and its equipment from MMHN for $200,000 per month, according to Laura Sanders, an attorney who works for Kim. A company called Salem Services, in which Kim holds controlling interest, was also formed ln return lor providing Aurora with a chief executive officer, chief financial officer, risk manager, and an administrative assistant, as well as other management sen/ices, Salem would be paid $100,000 per month plus an annual bonus based on Aurora's revenues, according to Salem's contract with Aurora. That deal was particularly lucrative for Salem, asserted Ftavitz, who said salaries for the four executives totaled no more than $500,000 a year combined, yet Aurora paid Salem as much as $1.5 million a year, according to the nonprofits filings with the lF`iS. ln mid-1998, two subsidiaries of the management company, Salem Hospital Pharmaceutical and Salem Transportation, also began providing service to Aurora, according to Salem's Web site. Another company affiliated with Kim, Marbella Management, leased at least two and possibly three outpatient clinics to the hospital. ln addition to its hospital lease, Aurora was paying as much as $580,000 per year to rent other tacilities, according to filings. The documents do not specify how much of that sum was paid to Marbella. Kim defended the overall arrangement. "The companies you mention provided much needed services to Aurora at market price or lower," he wrote. "Most of the entities were created to assist Aurora at a time when, because of its financial history and credit problems, Aurora was having a hard time finding service providers. lf the Salem-related entities did not agree to take the risks they did by entering into the contracts with Aurora, Aurora would not have been able to conduct its daily business activity." Board chairman Stone said they provided vital services that might not have been available otherwise. Stone also defended the practice of putting much of Aurora's business into companies associated with Kim; "He was providing us with sen/ices, and he's entitled tc be paid for services rendered," said Stone. Mel Fiavitz wasnt among the original board members recruited after Aurora was created in April 1997. He came on board in '98, after he left the City Council, where he had gained a reputation as a reformer. Page 3 of 9 Times 10/zo/10 9?54 PM ge had been recommended by Barbara Clark, a longtime employee of Michigan Health Care who had been hired by Kim to be ur CEO. a Clark and Ftavitz were friends, having worked together during the 1970s when Flavitz chaired the Detroit-Wayne County Mental Health Board and Clark worked forthe agency, "Barbara is a dedicated social worker, a person dedicated to providing quality mental health programs," said Ftavitz. "l have enormous regard for her and her integrity," ilitavitz said that upon joining the board he believed Kim was motivated to "maintain Aurora's high quality of care. But slowl ecame disabused of that notion as I learned more and more about him and how his operation worked." His concern spiked in 1999 as the nonprofit board discussed buying the hospital from MMHN. Hre worried about financial ties between Kim and some board members. As the owner oi a Southfield insurance agency, board airmen tone provided insurance coverage to Aurora as well as two other hospitals in which Kim had an ownership role: Greater Detroit Hospital, located on the border between Detroit and Hamtramck, and the Arborview mental facility in Warren. Stone said he checked with the state to ensure there would be no conflict of interest problems before he joined the Aurora board, and that the nonprofits bylaws allowed him to do business with Aurora as long as contracts he received were competitively bid, an obligation Stone said was fulfilled. Stone said he received about half of Aurora's insurance business; the nonprofit paid $130,000 to $200,000 per year for coverage, according to its IRS disclosures. "l'll sue anybody who says had a conflict of interest," Stone told Metro Times. Another board member, Steve Plotnik, was Kim's longtime personal accountant. Attorney Sweeney, who did legal work for several com a tf'l' nies a iiated with Kim, served as board secretary. Salem employee Carol Peart served as both Aurora's CFO and board treasurer. Letters Ravitz wrote to his fellow board members starting in January 1999 reveal his trepidation about the sale process. "How we proceed matter of concern to the entire community; its citizens are our patients," he wrote. The letters reflect Ravitz's view that the board was moving too quickly, and that his efforts to obtain separate advisers were consistently stymied, Ravitz also complained that the Aurora board was essentially given only two options: Allow Kim to sell the hospital to the for- profit Universal Health Systems, or int ct bt l: explore other options. 9 an uyt facility itself. Flavltz insisted that the board needed more time to "i appropriately and openly with every alternative professionally and objectively researched, then evaluated carefully by the entire board in the interest of the community we serve," he wrote in a March letter. no desire to stand in the way of helping Dr. Kim receive a reasonable offer for his reel estate but it must be done Then in April: 'For its own ethical and fiduciary protection, the Aurora Board should postpone its decision and authorize equa expenditures to engage appropriate professional consultants and extend the review period at least an additional sixty days for a complete investigation of suitable alternatives." ln April 1999, the board voted to buy the hospital from Kim. The appraised value ol the facility was $17 million to $19 million. Ravitz thought the price cutra eous, After ll MMHN a a purchased Aurora less than three years before for $4.2 million. Kim wrote to Metro Times that the more than four~fold increase was iustlfied because under SaIem's management "the operation had turned itself around so that the business value of Aurora had improved and became more valuable." According to Aurora's filings, the nonprofits revenues increased about 25 percent between 1997 and 2001, jumping from $19.4 million to $25.5 million. Ftevitz suggested that a 20 percent return on Kim's investment would be a fair price for the nonproht to pay it would provide Kim an $800,000 profit on his $4 million investment. By that point, Aurora's $200,000 lease payments to MMHN had already eclipsed the initial investment. Not to mention the $100,000 management fee that Aurora was paying to Klm's company, Salem. instead of taking on high-interest debt, Ravitz argued, a low-interest loan could be obtained from the Michigan State Health and Hospital Association, Fiavit; advised the board to borrow $6 million from the association. Then, instead of taking on the higher interest rates associated with issuing bonds, Kim could be paid off, needed improvements to the aging buildings could be made, and Aurora would remain an independent, community-based nonprofit. Pigv 4 ?f 9 M=1f? Times to/zo/to 9:54 PM "l do not suggest anything sinister on enybody's part," Ravitz wrote. "Nor do have a problem with an investor making a profit oft his investment, but that profit should not saddle the agency with a crushing debt it may be unable to pay." Shortly thereafter, Ftavitz said, St oar since he was so often at odds with his fellow board members. one asked him if he would "be more comfortable" resignin from the "Mei Ftavitz was a disturbing person on the board," said Stone. "He was always against everything that was happening. He was an agitator who thought he knew everything, but he wound up making a lot of bad decisions. He was the worst thing that ever happened to the board." Stone verified that he suggested Ravilz might want to leave the board. Ravitz didn't budge. "l em not uncomfortable being a minority board member," he wrote to Stone. "l have been in that role before. indeed, the purpose of all my letters has been to try to present what believe are the cold facts to the other members in the hope they would eventually see matters as I do. "As I . amostt ree decades. My sole interest is in seeing that Aurora Healthcare is able to continue to serve its patients and at the highestquality level possible. Unfortunately, that is not the case now. We have physical improvement needs. We have unusually high staff turnover. We are not paying our staff salary and benetits that will enable them to stay and develop loyalty to the agency." told you, my 'ties to Aurora go back to its inception it serves people who were my constituents for Board member me, were still going good. Cash flow was good, the number of patients was good." George Gaines Jr, said, "l think the rest of the board didn't go along with Ftavitz because at the ti thi ln retrospect, he said, Ravitz was prophetic. "Mel's warnings were a harbinger," said Gaines. CEO axed Around that same time. Aurora's CEO, Clark, began raising red flags of her own. Citing a confidentiality agreement, Clark refused to discuss any matters related to Aurora or Salem Services with Metro Times. However, her position was laid out in a presentation to the board on May 26, 1999. A copy of that document has been obtain etro Times. A big part of the problem was staff pay. As Clark put it, "Aurora has not made market adjustments to pay scales since the change in ownership." Consequently. the hospital had 17 nursing vacancies. That shortage, combined with what she described as "patient incidents," had aroused the interest of health care regulators. Clark wa - si en Aurora's board owed it an ethical obligation, caught in a tough spot. She drew her salary from Kim's for proiitoompany Salem but as re 'd i "Since have a fiduciary responsibility to the board," she said, "it is important to inform you that Aurora must seek a balance between the current administrative overhead costs, rent, management services, other contracts and investment in the staff and facilities." She urged the board to follow Flavitz's rmzommendation and create a committee to review financial reports, audits, the contracting process and expenditures. Doing so, she said, was "customary for board oversight." She also wamed: "Because Aurora is a non~profit service to indigent patients and families most of Aurora's income over expenses needs go back into programs and facilities in order to provide a quality sen/ice and be competitive. We have successfully operated in this rn riner in the past and believe we can he successful in the future." Also: "lf Aurora's financial obligations either through outside debtor current overhead are too high, Aurora will not be viable over time. This is evidenced by our current situation after two years." Within five weeks of making that report, Clark was fired. Kim would only say that she was let go because of "performance issuesf She filed a wrongful dismissal action against Salem, but because that complaint was settled in mediation and not in court, P192 5 9 Metre Time# 10/zo/to 9;s-i PM there is no public record of what transpired. Clark was awarded a settlement, according to her attorney, but she cannot discuss the case because of a confidentiamy agreement. (The firing of Clark mirrors an action at Greater Detroit Hospital, where CEO Linda Carroll was Hred after balking at what she described as l fa .L Yes We trust this will clear up any misunderstandings that Aurora ofhcials may have about the critical role UIC has played since 1994 on behalf of the Department by ensuring that wards are protected from harm. Now, if Aurora's position here is that they only wish to "collaborate" with staff- as opposed to, say, being scrutinized by UIC - they will need to explain why. However, in light of the GAO Endings about the validity of JCAHO's reviews - which Aurora officials indicated they prefer to a review by UIC - it does not seem likely that DCFS will ind any parallel explanation from Aurora ofhcials either reassuring or acceptable. 8 IV. Treatment Services Treatment Discharge Planning. The UIC reviewers see little need to respond to the comments by Aurora CLH oficials regarding this particular section other than to refer back to the relevant parts of the UIC report itself as well to similar Endings by JCAHO and IDPH reviewers - all of which are adequately documented or footnoted in the report. One item that ought not be ignored, however, is the puzzling reaction of Aurora CLH officials [see item on page 5 ofthe CLH reply] regarding the "rotation of injection site for PRN medications." Page 10 ofthe UIC report contains the following bullet-pointed paragraph, as well as the brief footnote and link reproduced be|ow:" Reviewers also noted that CLH nursing documentation often tacked indica- tions regarding injection rotation sites amts, thigh, buttocks, etc.) when patients were given IM emergency medications, making it difficult for QA staff or nursing supervisors/managers to track this quality of care indicator. The link tothe Nursing Times website leads to an article which offers the following advice regarding IM injection procedures: Complications Faiiure to rotate KM injection sites may resutt in srnali deposits of unaasorbed medicatson, some rotation of sites must be clearty documented to avoid this Sterile abscess; may ocrlir as a rsutt of injetzing an irrttant drug into the subcutaneous tissues. This GG he avoided by setecting a needle off appropriate The UIC report briefly cited this issue as a prelude to a discussion of a specific case - regarding MG, a DCFS ward at CLH who had received a combined total of at least 180 emergency medications (112 PO) during the period from June 7 to September 27) - although the issue of rotating IM injection sites clearly applies to all patients, especially those who might be receiving frequent IM injections in the hospital." For whatever reasons, Aurora oficials actually thought it wise to take the position that: "there are no mandatory requirements for documenting rotation sites when administer- ing injections"; this in addition to arguing that: nursing is unaware of any docu- mentation indicating that any patient has ever suffered from an abscess secondary to inject/ons, nor complaints regarding injection sites." While UIC, CMS, IDPH and even JCAHO have already identiied a range of concerns about CLH documentation, the team is now prepared to make the following offer: If any Aurora CLH official will volunteer to receive 112 IM injections (no meds, just the needles) without site rotation, UIC will graciously concede this point. 11 See advisory on IM injection issues in: ?Q;_articIe . See also: 7575642/Admin-am INI-Inections. lt should be added that this matter was initially raised by one of the UIC team members - an advanced practice registered nurse (APRN) with 30 years experience in nursing leadership - who was concerned that CLH nurses were either not aware ofthe site-rotation issue or were simply not documenting that they were rotating injection sites. Instead of seeing these comments as useful nursing feedback, CLH ofhcials responded argumentatively that since there are no "mandatory requirements for documenting rotation sites when adminis- tering frequent IM injections, nothing at all was wrong with their current nursing procedures. 9 V. Hospital and Unit Management Issues. As with the previous section, the UIC reviewers see little need to respond to objections raised by Aurora CLH officials regarding hospital and unit management issues other than to suggest a more careful reading of the relevant parts of the UIC report itself. But just as in the previous section, a few minor points are too instructive to ignore, especially insofar as they seem to shed useful light on the narrative spin of the Aurora response - and, arguably, on the cognitively deceptive manner in which Aurora officials habitually address (or deny) problems at their hospital. As was the case with the reported sexual assaults [where CLH official stated that "to our knowledge, there were no criminal charges or confirmed assaults made in any of these alleged incidents" and the issue of IM injection sites [where CLH held that "there are no mandatory requirements for documenting rotation sites when administering IM injections"j, Aurora officials seem to resist mustering the will for a serious and forthright discussion of the issues identified in the UIC report. Among their non~serious responses are the comments by Aurora CLH officials that "there is no regulation, standard, benchmark or data presented to support [the UIC "claim'j regarding inadequate stafhng levels at the hospital. Since UIC thoroughly dealt with this sort of misleading argument (about what constitutes adequate staffing levels in hospital units for children and adolescents) in a 2009 report to DCFS - and Aurora officials are already quite familiar with that report - we will simply refer both to our 2009 report as well as to the model guideline recommendations of the American Academy of Child and Adolescent It may be noteworthy that - as was the case with the hospital in the 2009 report - Aurora officials also fixate on the point that neither the AACAP guidelines or federal regulations "mandate" specific staffing levels, which is certainly true. But what this deceptively self-serving response ignores is the fact that the consequences for not providing "adequate stafnng" - however ill-defined that concept may actually be in current regulation or law - are measured by the occurrences of harm to patients or the demonstrable failure to provide needed treatment services to those patients, evidence from which certain outside reviewers may conclude that inadequate stafhng contributed to substandard quality of care or patient endangerment. Aurora corporate-level officials in California are well aware of this issue, as the UIC report indicated, so it is not surprising that local CLH officials wish to minimize or deflect any inconvenient focus on the adequacy of staffing levels at their hospital. Finally, Aurora CLH officials did manage to surprise us with their assertion that the UIC reviewers "incredibly found fault with plan to construct a new treatment facility." In fact, the reason that assertion is so "incredible" is that it's simply not true - although it is "not true" in a troubling way: it is a fabrication intended to deflect attention away from what the UIC report actually noted about this matter. We trust this misrepresentation can be understood in the context of the footnote pasted below (originally tagged as footnote 17 on page 16 in the original report): 10 As mdlaaiett amish lancwmu me De\2mhe' Z0 meemg maataw CLF Uthman an mwew a craft ul mo muon. the nomiws CEU naman email to Dr, Davidson and Dr Nzyivr making me use tor Venonsldorllron ol Uilial hnutlgh in the IBDQA, l00lT!L`l? 10 I D1 ansctal mural mu uttered the Fokowmg in net omni me mgaru me issue vw-1: ia sane-ns ss. 9 mon ul imfisnwe moniiofmg of panes: salety sm .nanny 3010. Munn Cmyucawna oduutsnal :runny me Aebouuewars 1 1 -..L EKEILQLEEI . nasal in eww. me CEU ns nate tm iwuftay utrme ot tht! FWGIHUS XFX UPG UIC YBDOYKI CLH 15 MEN ls mum an mnwumqm pawn! Safely as any timed eupervtsim by - a crromc nmmom mai me Aufora iaorwrwon :pours to be suggesting ri tm emu an oe curse by armory a ical esuk Uvisacucn whsle me UlC\ea1n wautzl certainly me mhernnt Mil" layout in (UCL II Watt l|tY\5|w8lZ6d if\ Dhgram - me tau cl new cnysiosi point weston dues nm allow hosateiaamlnistrawrs to avoid umng msunnsioiliiy tor inadequate susan/won, Guns me cummrx, B5 UNB Bmiil |1hl1?tNl\` B1 CLH YIIVQ auttamd narm because ine or cam* |\aamd| 'uns ol UIQIHUUBIIMW liiffb resolve misawlnyulclru ln the tour aus ot Mensa described earlier. new mmnee snvoh/me an etemeni ol lunovvulon #nuns mai unnamed lobe 11 lent mmpoumod by poor ima-at-ugm on thu mid. oomncuvs adtnn vssaomwi Dy CLH however, nolrwno mostly to vmous at me eval nlstall nuoervmon me (num to oruuseuros, Sikh ns connuctmq mom cnecxs uno posting ia tremor me nursing muon tin anal ni vnu hallways could be hmy olnerveoi onluren is nexusetul the meme nonmwam nom mloiui snail wmwliy v/mn it now seams char mat mrparnu athmuss were luliy aware that this patient :amy issue :ignores nn organ|Ja\\on9i1a12me - 1 Contrary to the bizarre assertion by Aurora CLH ofhcials, then, the UIC reviewers did not "incredibly find fault with plan to construct a new treatment facility" ln tact the UIC team will happily show up for the ground-breaking ceremony, assuming that we are invited. In the meantime, attention is drawn to that part of the above tootnoted comments by the UIC reviewers thatAurora officials most wanted to avoid: ln effect, the CEO is implicitly acknowledging here the accuracy of one of the main Endings in the report: that the CLH physical plant is itself as much an impediment to patient safety as any failed supen/ision by staff - a chronic prob/em that the Aurora corporation appears to be suggesting in this email can be cured by simply initiating a rea/ estate transaction." lnasmuch as this email tacitly admits that "vulnerable children" at CLH have suffered harm because the "environment of care" [lacked] "line of sight" that would allow staff to conduct effective monitoring, Aurora/CLH ofHcials now have an even greater duty to resolve this quality of care failure. No further comments about this matter would seem to be necessary. Vl. Corporate-level Quality of Care issues. Aurora CLH officials stated that they "do not dispute that [the hospita/'s] relationship to its owners may be relevant" as a subject to be examined in the report to DCFS. Nevertheless, they quickly reverse course to argue why the extremely troubling history of corporate behaviors itemized in the UIC report ought to be ignored by DCFS as having no bearing whatsoever on the treatment of the Departments wards at Aurora's Chicago Lakeshore Hospital. According to Aurora officials, the report failed to "connect the dots" or "offer proof" that past or current corporate behavior might be relevant to whether a local corporate- owned facility, such as CLH, is adequately staffed or resourced. Despite such objections - saying, in effect, that well-documented occurrences of poor quality of care and harm to patients (including deaths and sexual assaults) in other Aurora hospitals should really not be of any concern to DCFS -the UIC report has demonstrated that examining the performance history of this (or any other) healthcare organization is directly relevant to the Department's fiduciary duty of care toward its wards. Moreover, in what may be the most revealing look at the Aurora corporate strategy for dealing with the intrusive oversight occasionally posed by outside reviewers - especially government healthcare authorities, such as the federal Centers for Medicare and Medicaid Services - Aurora ofhcials argue in their response to the report that "the threat of desertification from Medicare is standard language from CMS when.., it investigates an incident involving patient In fact, this statement is so breathtakingly deceptive that Aurora ofhcials will most likely come to regret ever making it, but not simply because it is easily debunked as part of the narrative intended to mislead DCFS, Rather, when reduced down to its cynical core the statement is consistent with a corporate history of treating CMS findings about substandard care and harm to patients as little more than a cost-of-doing-business - something that can be managed by producing corrective action plans and offering new assurance to do better in the future. Our point here is quite simple: if Aurora's corporate ofhcials so arrogantly manipulate federal healthcare authorities with corrective action plans and assurances, DCFS has every reason to be concerned about its dealings with this organization. 1 - CMS does not "threaten decertitication" whenever it "investigates an incident involving patient care" - meaning that the Aurora statement, if it were to be taken seriously, is the equivalent of saying that traffic courts normally hand out life sentences to motorists who run stop signs. The truth ofthe matter is that CMS and Califomia health authorities found recurring evidence of substandard care and harm to patients at Aurora's hospital in Los Angeles -including the case of a 14-year-old girl who was raped while staff slept - as was documented in the UIC report. Now, as for the purported failure by the team to "connect the dots or "offer proof' that Aurora's past corporate behavior might be relevant to whether CLH is adequately staffed or resourced, federal officials have already made that case for us, as evidenced in the following clip taken from a 2008 CMS report on the Los Angeles hospital [see UIC report, page 18]. The hospital failed to implement staff-to~patient to ensure that all patients were monitored and kept safe in a secure environment [and failed to ensure that employees assigned to monitor patients on a 1:1 basis had no other responsibilities that would interfere with their assignment. 12 Finally, it seems useful at this point to again refer to comments made by a federal official who had apparently experienced no small amount of frustration over the repeated efforts within his agency to hold Aurora accountable: "Every hospital must have a system in place to review incidents, review procedures, improve operation, correct deticiencies, not wait for a survey to come along and point out problems, "lt's not untypical to #nd problems at hospitals. What is unusual is for there to be major issues and not have the problems Hxedn. But at Aurora, you had a situation where they were repeatedly falling to hx deficiencies. In fact, they had even more problems in August than in January, Then a survey in October stil/ found problems. 1" Clearly, any similar assurances made to the Department by Aurora corporate officials - especially when suggesting that their past corporate behaviors are not relevant to the task of determining whether DCFS should place its full confidence in this organization - ought to be examined in light of the cautionary tale recounted above. l. "Aurora Goes Dark: Requiem for a Ward"; second of two parts in the Metro Umes; January 15, 2003. 13 VII. Case Reviews of DCFS Wards at CLH. The UIC team selected the cases of tive DCFS wards - out of the several dozen case records that were actually examined over a period of several months -forthe purpose of discussing a range of quality of care concerns that were identified during the course ot reviewing medical charts, treatment/discharge plans and other clinical records. Aurora CLH officials responded to these five case discussions in the UIC report, and we have provided some brief follow-up commentary below where necessary. Case 1: MG. While MG was arguably the most complicated of the five cases, there is little dispute on the basic facts: a 113-day hospitalization at a combined total of at least 180 emergency medications (112 lM/68 followed by a requested transfer to the CATU program at the Medical Center, where MG received only about a half-dozen emergency medications during an equivalent 100-day period." For our part, the UIC team has no intention of "re-lltigating" case, point-for-point, with Aurora ofhcials, particularly insofar as most of the counter-points raised in their response are either: obfuscations that lead away from any serious discussion of the core problems identified in the UIC report; or non-responsive and misleading digressions about issues never even raised in the report (simply put, smokescreens that contribute nothing to a genuine understanding of this ln sum, Case 1 is well-documented and requires no further comment or defense. The team therefore stands by its original conclusion: that MG's treatment for prolonged periods ot time at CLH appears to have unfortunately centered around behavioral management by emergency medications, with no clear behavior plan and ineffective or uninspired pharmacotherapy. The UIC team recently learned that MG was discharged from CATU to the care of his grandmother, where he has reportedly been doing well forthe past six weeks and has also remained medication-compliant. 15 Aurora officials incorrectly stated that UIC merely conducted a "desk audit" of MG's charts ignoring the fact that he was interviewed several times by two UIC team members (both at CLH and later at one of the UIC reviewers also attended a CLH clinical stafhng to evaluate the team's treatment and discharge planning efforts for and another reviewer later made a DCFS hot-line call after MG complained to her that he had been abused in his foster home. Further, Aurora officials ignored footnote 34 on page 27 of the report, which is pasted below, perhaps because it undercut their specious narrative about UlC`s "desk audit" of this case. Dr. Naylor, in his role as consultant for the UIC Mental Health Policy Program, discussed the issues of MG's case with the CLH medical director by telephone as well as during the exit inten/iew with CLH ofhcials on December 20; he also discussed the case management issues at length with MG's attending Dr. -, who agreed that such frequent utilization of emergency medications was not ideal. Finally, Dr. Naylor was somewhat irritated to read in the Aurora response letter that "no treating were interviewed during the review, with the exception of one attending at the insistence of CLH after the exit interview in December 2010_" ln fact, Dr. Na lor told the Aurora CEO and medical director during the December 23 meeting that DR. had not returned his repeated phone messages, which they promised to remedy immediately. For these CLH ofncials to subsequently write that Dr. Naylor only contacted MG's attending at the insistence of more than a bit disingenuous. 14 Case 2: PC. For the most part, the UIC report was more critical of DCFS in this case than CLH, noting that PC "remained for a total of 154 days, apparently because DCFS could not tind an appropriate discharge placement." What is puzling, therefore, is that the Aurora response seems to imply that the UIC reviewers were being critical of CLH, not DCFS, for this interminable problem. On the contrary, the following paragraphs regarding PC show that UIC recognized that CLH clinical staff worked diligently to get this patient out ofthe hospital: Based on the review of PC's medical records at CLH, this case - and to some extent the case of MG, cited above - should be viewed as instructive for DCFS as a worrisome example ofthe systemic failure to ensure that such youths do not /anguish in hospitals for reasons unrelated (or secondary) to the mental illnesses that originally prompted their admissions to inpatient care. [D}uring this tive-month waiting period, PC 's clinical condition was observed to deteriorate (as indicated in various chart notes by CLH clinical staff). This is followed by a series of progress notes in Decemben "Pt presents as depressed and frustrated due to placement issues",' "Pt's [aggressive] behaviors are exacerbated by the placement de/ay'$ 'Pt presented with depressed mood because of being in the hospital for Christmas holidays? Pt admits to getting frustrated, especially since he has been here 112 days due to placement issues. CLH progress notes indicated that the hospital social worker repeatedly contacted or left phone messages with a DCFS representative about the ongoing lack of progress in finding a discharge placement for PC. While the team would have appreciated an acknowledgment from Aurora CLH officials about our "even-handedness" in distributing criticism - not to mention our willingness to compliment their clinicians - we understand why they are reluctant to disrupt their current narrative. Nevertheless, for our part the UIC reviewers have no such reluctance in acknowledging that whoever wrote the CLH response about the case of PC discovered a minor error on page 37 of the report - although it is not quite what it might seem upon reading Simply stated, we agree that this existing bullet-point on page 37 is factually wrong: Additionally, no attending notes were found in this chart for the 24-day period between 11/5/09 to 11/29/09. More important, however, a UIC team member caught this error in mid-January while double-checking the notes of a second team member who made the original error. Dr. Davidson was subsequently notified about this error in an email message, which included 14-pages of unedited notes on PC's case (part of which showed that the two- line bullet-point above was incorrect). While that email to Dr. Davidson should have been the end ofthe error, the fact is that the correction was never entered into the hnal copy of the report that was sent to DCFS in March and later forwarded to CLH. ln short, the reviewers are happy to correct this technical error on our part, and we will do so in a straightfon/vard manner- that is, not by simply "disappearing" the incorrect bullet-point but by highlighting the error itself in a footnote on page 37. 15 Case 3: DB. Similarly, as with the case of PC, Aurora oflicials took no note ofthe complimentary remarks by the UIC reviewers regarding the handling of DB's care, as indicated below: On a positive note, frequency of contacts with this patient appeared good in four of the six charts reviewed; additionally, the length of time spent with the patient was usually indicated in these charts (possibly because revised hospital forms now prompt for that required infonnation)_ At the same time, Aurora ofhcials ignored the main points of DEI's case review by UIC: Four of the six CLH treatment plans for this youth appeared boiler-plated possibly because the nurse who completed the ITP form had not read the clinical information available from admission. For example, in one treatment p/an - as well as in the initial assessment, social assessment and discharge summary -there were no references made to DB 's high-nsk behaviors (persistent suicidal idealion and gestures throughout his admissions, impulsivity and aggression), while another plan contained no reference to his explicit threats to kill his mother and her boyfriend. Similarly, RN daily assessments, daily How sheets, and the points and levels I wor aets a so appeared boiler-plated (most of the latten for example, were not completed by staff on the PM shift). Aurora ofticials also ignored footnote 38 of the UIC report, which is pasted below, perhaps because it indicated that certain issues identified by UIC - such as the content, accuracy, timeliness and quality monitoring of patients' treatment plans, evaluations and other medical records - were also identihes in a 2008 survey conducted by IDPH on behalf of CMS: 3* Reference is again drawn lo footnote 12. above, which cited a 2008 CMS report on CLH that identified certain deficits regarding discharge/aftercare issues - including the content. accuracy. timeliness and monitoring ot patients' treatment plans, evatuations and other medical records. ln tight of the mullipte adrrtiaions often mrperiencod by DCFS wards not;usr CLH - it should be understood that the UIC team focuses on such "paperwork details" as one element in an integrated quality of care review. .KB According to Aurora's narrative, problems identihed by UIC are not valid at face value and when such problems are inconveniently identified by other outside reviews as well (whether by IDPH, CMS or JCAHO), they simply are not to be talked about. Finally, the UIC report noted that DB was admitted to CLH on six occasions from Lawrence Hall Youth Services since 2009; the third and fourth readmissions in 2009 occurred approximately one week following discharge from CLH. While Aurora ofhcials decided not to address this point in their critical response either, the UIC team included DB and other such cases in an extended data review of frequent re-hospitalizations of DCFS wards; accordingly, we will continue examining this case and may submit an addendum ata later date if necessary. 16 Case JD. Aurora oficiais do not have much to say about account ofJD case although they ignored the fact that UIC noted he had been admitted to hospitals approximately 16 times since 2003, including six CLH admissions from LHYS between tate-2008 and mid-2010. For easy reference, the entire summary of JD's case in the UIC report is pasted below ti y, "at?gpoyanuw Thema., it ja; I _aes 2 aw 1 rr,_ ex time . oiri 1_7 5 fi ?52 tsaise z~ . rirt bf 1 if>,if ,rr _f mm. `fP'!'Q'Q'fl 3 7 ff #5 eirr. Of interest, the Aurora response to the UIC analysis of JD's case concludes with the statement that: "in light of lhis incident, the policies and procedures govern/ng the labeling of charts and Medication Administration Records to signal drug allergies was re viewed." Case 5: AG. Interestingly, Aurora officials had even less to say about analysis of Case 5, AG, than they did about Case 4 - and what they did say was essentially consistent with UlC's account - although they failed to mention AG's six admissions to CLH, two of which occurred within a few weeks of discharge from prior stays at the hospital. Again, for easy reference, the entire summary of AG-'s case in the UIC report is pasted below, along with two relevant footnotes from the UIC report: ffif #Wir PM 'ttit itiis was im tiwi- i lii 'i'i >>1ii t, .tri A ittrriir _unmaparawgi Kky, Ri 'fe #imma s,.s For anarnple. Ovydriatric progress name in me February and June 201C onarts aernonslrated therapeutic rapport with the patient and. unlike some admissions, it was deer that the Md actually met with the nezhsm in address tmetme issue; touch as medrmtacn noncompliance and repeated hosoilalizanonslt As nomo earlier in toomote 71, the reviewers and JCAHO surveyors found ngnilicsnt pmbiems with progress mins and other areas of madimi docurnsnutlon mat are the urimnry means nt evohmmg wnet is occurring in treatment and ensuring that putiems are moevnng care. in Amit 2010, for example, the JCAHO surveyors noted natiavat mans that were were 'moomplera and had omiswons of whole alinformeuoe, and/br blank .mucus for reviewers also idenliriod similar defrdencses in ssmnivng nf CLH mens met was oonswdevabiy larger than the JCAHO sample, 4 18 The UIC reviewers would also point out two inconvenient facts: first, that the Aurora response ignored mentioning that a 2010 JCAHO survey identified similar problems with CLH documentation as did UIC (specifically, with regard to the JCAHO findings, charts that were "incomplete and had omissions of whole sections of information, and/or blank spaces for required information"); second, that even when the Aurora response offered a grudging acknowledgment about positive remarks in the UIC report, the narrative still implied a sense that CLH was being unfairly "picked on" by Summary. In fact, while the latter narrative about feeling "picked on" resounds throughout much of the Aurora response to the UIC report, we appreciate that this has been a difficult time for Aurora CLH officials and their staff - and not only because of the stress of the review bythe UIC team. More to the point, we suspect that the current argumentative tone of the CLH response - which was not present either in the December 20 meeting or the emailed follow-up on December 23 - is driven both by concerns about news media attention in Chicago as well as acute pressure from corporate officials in California to essentially defend the indefensible. With regard to the second issue, we see no need for further comment. However, as for the problem, the UIC team has made every effort to identify areas of organizational strength and quality of care at CLH, and the reviewers underscored positive findings at numerous points in the report. While we found much to criticize about the troubling history of corporate behavior- including harm to patients and a pattern of substandard quality of care in other Aurora-owned hospitals - our final recommendation to DCFS was supportive: "to continue conducting unannounced reviews at this hospital over an extended period, with a special focus on the issues of ensuring effective staffing levels, staff supen/ision and monitoring of patient safety." CLH officials indicated that they hoped for "a fair, balanced and objective assessment of [their] ability to care for DCFS wards." Despite certain objections to the contrary, the UIC team believes that it has provided that assessment; at the same time, CLH must recognize that DCFS now has a higher level of performance expectations than before, and the UIC report also provides guidelines for measuring performance accountability. For example, the Aurora response regarding Case 5 stated that "it is important to note that there is no mention by [the UIC team] that AG's care or safety was in any way compromised." Ot course not, especially since most ofthe UIC analysis of AG's case was intended to suggest ways that CLH clinicians could improve their treatment approach (and certainly their treatment documentation) with this patient. 17 The point here is that Aurora officials somehow managed to find a way to focus on a non-event - UIC didn 't say that we comprised this patient's safety or care - while also ignoring what is, in effect, an inconvenient counter-narrative (namely, the fact that the UIC team actually made some very complimentary remarks about their work with Case 5). As a case in point, the UIC report noted "improvement with regard to progress/discharge notes, suggesting a commendable effort on the part of CLH officials (as indicated in minutes of the Medical Executive Committee) to pay closer attention to such problem areas. Similarly, the UIC team found that progress notes in the February and June 2010 charts demonstrated therapeutic rapport with the patient and, unlike some previous admissions, it was clear that the had actually met with the patient to address [his] treatment issues (such as medication non- compliance and repeated hospitalizations)." 19 Chica Lakeshore Hos ital 4840 North Marine Drive chicago, Illinois 606404220 rex (773) 907-45071 Phone (773) 878-9700 MAY 13 201| May 12, 2011 MLCOUNSE Mr. Erwin McEwen Director Office of the Director Illinois Department of Children and Family Services 100 West Randolph Street, Floor Chicago, IL. 60601 Dear Director McEwen: On behalf of Chicago Lakeshore Hospital, I wanted to thank you for what we found to be a very constructive meeting on May 11, 2011. I hope you agree that our discussion will enhance the ability of our partnership to meet our common goal of providing safe and high quality mental health services to wards of the Department of Children and Family Services We appreciated the opportunity to hear your goals for services to these children and as we said during our meeting, these are goals we share. Collaboration with DCFS built on a foundation that values open communication and cooperation benefits everyone. Our meeting was convened pursuant to the process outlined in Policy Guide 98.4 allowing for comment prior to your issuance of a final report. We understand from our meeting, that your final report will include the March 2011 Review of Chicago Lakeshore Hospital prepared by the Mental Health Policy Program Department of University of Illinois at Chicago(the "Review") and any subsequent written submissions relating to the Review. As you pointed out, there are no outstanding issues requiring a plan of correction or any sanctions resutting from the Review. We urge anyone inquiring about the quality of care of DCFS wards at CLH, to read your entire report including our comment letter of April 14, 2011 and these nnal comments. Although, no plan of correction is required, we assure you that we remain committed to a rigorous program of quality improvement for all of our patients including wards of DCFS. We welcome further unannounced visits to CLH by DCFS and view those visits as important in maintaining our commitment to transparency. Just as important however, is the agreement we reached in our meeting to engage in an ongoing dialogue with DCFS to identify ways in which the care of these children can be improved. Specifically, we agreed to work with your clinical team over the next few weeks to develop mutually agreed upon continuous performance improvement initiatives. We look fonivard to collaborating with DCFS for the benefit of the children to whom we share a commitment. Sincerely yours, C. Alan Eaks Chief Executive Officer CC: Dixie Lee Peterson, DCFS General Counsel tiictso Governor Illinois Department of Children Family Services VIA MESSENGER March 31, 201 Mr. C. Alan Eaks Chief Executive Officer Chicago Lakeshore Hospital 4840 N. Marine Drive Chicago, Illinois 60640-4220 Re: Indeoendent Utilization Review QIURQ of Chicago Lakeshore Hospital Dear Mr. Eaks: Enclosed is a copy ofthe report ofthe Independent Utilization Review (IUR) of Chicago Lakeshore Hospital. Please review, and if you wish to submit a response, please do so in Writing within ten (10) Woijking days. eg: U%uly yours, QQ /f e/ Peterson Gener Counsel cc: Erwin McEwen, Director Ron Davidson, UIC Office ofthe Director 100 West Randolph Street, Floor 0 Chicago, Iliinois 60601 312-814-2074 I 312-814-1888 Fax (R) CouNcn_ on Fon Cm\_onEN AND