Report: Haven Behavioral Health

Haven Behavioral Healthcare is a privately owned for-profit mental health corporation. It was founded in 2006 and is headquartered Nashville, TN.[1] 

Haven operates seven acute care psychiatric hospitals in six states—one each in Arizona, Idaho, New Mexico, Texas, and Ohio and two in Pennsylvania, as well as two offices in Pennsylvania that solely deliver outpatient treatment and counseling. 

Some of their facilities offer adolescent inpatient treatment in addition to inpatient services for adults. State health department inspection documents also indicate that they treat the geriatric population as well. According to the findings of these reports, many of the violations that Haven facilities commit involve failure to properly care for its geriatric patients, particularly in the case of patients who are at risk for falling. 

Haven’s annual revenue is $138,457,908.[2]

LIST OF CURRENT HAVEN FACILITIES 

Haven Behavioral Hospital of Albuquerque - Albuquerque, NM 

Cottonwood Creek Behavioral Hospital - Meridian, ID 

Haven Behavioral Hospital of Dayton - Dayton, OH 

Haven Behavioral Hospital of Frisco - Frisco, TX 

Haven Behavioral Hospital of Philadelphia - Philadelphia, PA 

Haven Behavioral Hospital of Phoenix - Phoenix, AZ 

Haven Behavioral Hospital of Eastern Pennsylvania - Reading, PA 

Berkshire Psychiatric (outpatient) - offices in Wyomissing and Reading, PA

TIMELINE OF ABUSES 

August 4, 2011: DRUGGING WITHOUT CONSENT – The Arizona Department of Health (AZDH) determined that Haven Phoenix failed to obtain informed consent for psychotropic medication in eight of 10 cases reviewed and also failed to obtain written informed consent for voluntary hospital admission in six of 10 cases reviewed.  

September 21, 2011: PATIENT ABUSE & NEGLECT – The AZDH found that Haven Phoenix failed to ensure that a patient who was physician-ordered to have line-of-sight supervision received such. The patient fell, unwitnessed, and hit their head. The patient records clearly showed the physician’s order for “…strict line of sight for safety….”[3]  

In five of five cases reviewed, AZDH determined that Haven failed to obtain a physician’s modification of the patient’s care plan before instituting restraint or seclusion actions upon the patients. Haven also failed to do face-to-face assessments of physical and mental status of these patients within an hour of restraint actions, as required. One patient fell down following restraint and sustained injuries to the face and forehead.  

In another case, Haven failed to obtain a physician’s order for physical restraint of an agitated geriatric patient.  

Haven failed to provide a safe environment for patients as evidenced by failure to prevent one patient from physically assaulting another.[4]   

August 21, 2012: An AZDH inspection found that Haven Phoenix bypassed a patient’s Power of Attorney (daughter) when developing the patient’s treatment plan, in violation of their own policy which provides for the Power of Attorney to review the treatment plan and sign off on it—or not.[5]  

March 29, 2013: VIOLATION OF PRIVACY, DRUGGING WITHOUT CONSENT – An AZDH inspection found that Haven Phoenix violated a patient’s right to privacy (per Haven policy) by having a suicidal patient sleep on a bed in the hallway near the nurse’s station so that nurses could maintain line of sight during the night shift. Four Haven employees interviewed about it confirmed that this is common practice. Another employee reported that he’d observed a patient placed on a mattress in front of the nurse’s station during the night shift.  

The same inspection states that Haven violated their own policy with regard to patient (or patient’s representative’s) consent for administration of psychotropic drugs. In the case, Haven had a signed consent from the patient’s representative (daughter) for three oral psych drugs: the antipsychotic Seroquel, the antidepressant Remeron, and the tranquilizer Ativan. Evidently, the patient refused to take them and was injected instead with the antipsychotic Geodon—for which no consent was documented. Haven also administered the antipsychotic Risperdal and the mood-stabilizer Depakote orally, without documented consent. Haven additionally failed to comply with the patient’s advance directive.[6]  

April 12, 2013: Angela Cavaliere sued Haven Behavioral Hospital of Eastern Pennsylvania and psychiatrist Yogesh Maru for negligence. The suit settled on October 8, 2015.  

2014: PATIENT DEATH – A 2014 consumer review on the website Vitals.com of Cottonwood Creek psychiatrist Roberto Negron regards the deaths of a child who was under Negron’s treatment:  

“I remember sitting in Dr. Negron’s office with my daughter with his tape recorder taping our session as he asked my daughter questions and how she told him she was having thoughts of suicide since she'd been on the drug Paxil. I asked him then if he would admit her into the hospital to wean her off of the drug so that she could be monitored by professionals. He refused and wanted to increase her Paxil and add another drug to the mess. We told him we didn't agree and [asked] what was the worst symptoms she would experience if we weaned her off of it, to which he replied ‘flu-like’ symptoms for 2-3 days. Then we proceeded to ask him how to wean her off of it as he answered my question not bothering to look while writing another prescription. My child is no longer here due to his negligence. I would warn anyone who has a child to beware taking their child to him. I saw him a few years ago and asked him if he remembered me and my daughter to which he replied, "You haven't gotten over that yet?'”[7]  

April 7, 2015: An inspection of Haven Eastern Pennsylvania by the Pennsylvania Department of Health found that the facility failed to have a system in place to ensure that a patient's family/other representative and their physician were contacted as soon as possible after the patient was admitted to Haven. This involved two of three patients whose records were reviewed and showed that Haven did not even document asking the patient if they wanted their physician contacted.[8]  

May 14, 2015: PATIENT NEGLECT – The New Mexico Department of Health (NMDH) conducted an inspection of Haven Albuquerque which found that the facility failed to analyze eight of nine patient falls—most of them with injury—so as to ascertain the cause and work to prevent it. The only reason Haven did an analysis of the ninth patient’s fall was due to requests from an accreditation agency and the patient’s insurer.[9]  

June 18, 2015: PATIENT NEGLECT & ABUSE – NMDH determined that Haven Albuquerque failed to ensure that there were adequate numbers of behavioral health technicians to provide care to all patients, as found in the instance of three patients who suffered falls and medication errors. One staff member interviewed by NMDH stated that patients fell while the Director of Nursing sat by, and did not move to assess the patient and that staff were aware of another geriatric patient that fell on a Friday but who was not sent out to a medical center until the following Tuesday, with a fractured pelvis. This latter patient situation was noted by NMDH as a violation by Haven of a patient’s right to be free from abuse/harassment.  

Further, NMDH found that the facility’s Infection Control Officer (a job held in this facility by the Director of Nursing) did not have any current training and did not carry out facility-wide inspection, evaluation and disinfection following a norovirus (stomach flu) outbreak.[10]  

July 30, 2015: DRUGGING WITHOUT CONSENT – Haven Phoenix failed to obtain documented informed consent for psychotropic medications in of four patient cases reviewed. In one case, Haven had obtained informed consent from the patient’s Power of Attorney for the use of Seroquel, Depakote, Ativan, and Celexa yet Haven injected the patient on two occasions with Haldol for agitation and administered Risperdal orally for nine days in absence of documented consent. In the second case, Haven injected a patient with Haldol on three occasions and Ativan on one occasion for agitation, as well as administered oral Risperdal on one occasion, all without documented informed consent.  

AZDH also found Haven to be understaffed, which “has the potential to cause patient harm by not meeting the patient’s physical and mental health needs.” The state’s inspection report gives the numbers, which show that each nurse is being called up to handle more patients or a greater number of complex/difficult patients than policy allows, including a nurse and behavioral tech each assigned two patients requiring 1-on-1 supervision.[11]    

September 16, 2015: FAILURE TO REPORT INJURY – The Pennsylvania Department of Health (PADH) found that Haven Behavioral Hospital of Philadelphia failed to report and investigate patient injuries of unknown origin to rule out abuse in two of five cases reviewed. Both patients were geriatric and did not know how they received their injuries. Haven policy states “All licensed health care facilities shall immediately report abuse, neglect…to the adult protective services division” 24 hours. This was not done.[12]   

January 19, 2016: PATIENT DEATH – A wrongful death lawsuit was filed against Haven Behavioral Hospital Albuquerque and psychiatrists Anthony Holzgang and Kathleen Johnson regarding the death of a patient named Tim Waters. Trial occurred mid-February 2019 resulting in a verdict in the defendant’s favor.  

February 19, 2016: PATIENT NEGLECT – Texas Department of Health (TXDH) found Haven Behavioral Hospital of Frisco failed to provide nursing services and supervision by a registered nurse: (a) nurse failed to supervise and evaluate a patient who required assistance for toileting who fell twice, requiring emergency care for a head injury; (b) nurse failed to evaluate/reassess and perform neurological check for a patient who sustained multiple falls and subsequent head stitches while admitted to Haven; (c) nursing staff did not recommend a nutritional assessment for a patient who had not eaten for three days prior to admission. Patient was transferred to a medical hospital for hyponatremia (dangerously low blood sodium).  

Additional findings:  

o   Haven Frisco’s service quality data from December 2015 showed that 25% of harmful patient incidents involved a fall. Its service quality data from January 2016 showed that this figure rose to 45%. Haven had identified a need for improvement but did not take the necessary steps; patient falls continued to occur.  

o   Though a physician ordered neurological checks for the aforementioned head injury patient every four hours, no such checks were found notated in the patient’s medical record. The patient later fell yet again, resulting in a fractured hip.  

o   TXDH also found that Haven was lax on infection control—a litany of observed unsanitary conditions—and also violated patient rights by failing to provide a safe patient care, as patients had access to objects—CD, dominos, plastic bags, plasticware, etc.—which could potentially be used for self-harm or harm to others.[13]  

August 5, 2016: A state health department inspection found that Haven Eastern Pennsylvania failed to evaluate the reason for the readmission of patients within 30 days of discharge—i.e., whether readmissions were due to a problem in Haven’s discharge planning.  

Haven additionally failed to handle a grievance as such: A geriatric patient advocate called and “yelled about the discharge plan and that the patient had been readmitted to an acute care hospital the day after discharge.” Haven did not treat this as a grievance though it was later revealed that staff considered it a grievance per Haven policy.[14]   

June 21, 2016: DRUGGING WITHOUT CONSENT – The Ohio Department of Health (ODPH) conducted an inspection of Haven Behavioral Hospital of Dayton which found that a nurse at the facility failed to obtain the consent of a geriatric psychiatric patient’s health care power of attorney for administration of newly-prescribed psych drugs (first time), which included Haldol, Depakote, Clonazepam, and Zyprexa.[15]  

October 25, 2016: PATIENT NEGLECT – Haven Phoenix failed to employ or schedule an adequate number of nurses based on requirements, which placed geriatric patients at risk. Three patient were thus allowed to suffered falls, one of which required a trip to the emergency room for evaluation and suturing.[16]  

January 13, 2017: PATIENT DEATH – Kelly Garner filed a wrongful death lawsuit against Haven Albuquerque and other defendants. The suit settled in February 2022.  

January 27, 2017: PATIENT NEGLECT & INJURY – An ODPH inspection of Haven Dayton found that the facility violated patient’s rights by failing to ensure that (1) injuries of "unknown origin" were investigated; (2) interventions to prevent patient falls were identified on admission; (3) post-fall assessments were completed; (4) a physician order was obtained for the use of a restraint, and (5) 15-minute checks were completed according to policy and procedure. This involved the care and safety of nine geriatric patients. In one instance, a patient requiring 15-minute checks was found to have been checked for a total of one hour over one evening. The next day the patient was found to have a fractured elbow, left arm bruised to the fingertips, and bruising to both eyes. No documentation of an investigation was completed until six weeks later.[17]         

March 15, 2017: The AZDH found that Haven Phoenix failed to ensure that seven of seven mental health technicians reviewed were trained in competently moving or transferring patients and providing pericare (washing of the genitals and anal area) of female patients, as evidenced by a technician orientation-training grid which did not include moving-transferring patients or peri care. Further, it was found that the facility had many exposed ligature points (objects, such as faucets, long electrical cords, handles) which one can use to hang themselves).[18]   

July 7, 2017: PATIENT NEGLECT – A TXDH inspection found that Haven Frisco failed to follow its own policy of assessing during each shift patients considered to be at high risk for falls. This involved two patients, which TXDH observed to be without shoes or non-slip socks on their feet.[19]  

December 5, 2017: PADH found Haven Philadelphia failed to ensure medications were stored in a secure manner; failed to ensure that patient care supplies and equipment were maintained in an acceptable and safe manner, as evidenced by numerous observations of date-expired items, including catheters, saline, and hydrogen peroxide, and equipment which was long overdue for routine inspections and maintenance.[20]  

February 8, 2018: DRUGGING WITHOUT CONSENT – Haven Phoenix failed to obtain informed consent prior to administering psychotropic medications for seven of eight patient records reviewed by state health department inspectors.[21]  

March 20, 2018: PATIENT ABUSE – A NMDH inspection found Haven Albuquerque to have violated  patients’ right to care in a safe setting, based on two geriatric patients who reported similar abuses (roughly shoving a towel into the patients’ groin/rear end) by a staff member of which each patient provided a similar description.[22]   

March 30, 2018: PATIENT DEATH – Marc Grano filed a wrongful death lawsuit against Haven Albuquerque and other defendants in the death of Della Venegas. Court records show that the jury was selected and trial was scheduled to proceed on January 4, 2022.  

April 18, 2018: Haven Phoenix failed to provide orientation to agency personnel (mental health technicians hired on a temporary or as-needed basis), which posed a high potential risk to patient health and safety, as facility can’t confirm that personnel are orientated to their job. In this instance, AZDH investigators requested a copy of the technician’s orientation checklist. There was none. The technician reported he’d worked at Haven Phoenix four times and was never oriented, trained, directed or informed of facility policies.[23]  

June 21, 2018: PATIENT DEATH – Haven Phoenix failed ensure that physician orders were written for a patient related to dietary needs after the patient developed difficulty swallowing. Due to this information failure, the patient was fed food which he could not swallowing resulting in two choking episodes. The patient died after the second episode, in which a mental health tech had given him crackers to eat.[24]  

July 3, 2018: PATIENT DEATH – Linda Hardy filed a wrongful death lawsuit against Haven Albuquerque.  

September 20, 2018: PATIENT NEGLECT – An OHDP inspection found that Haven Dayton failed to ensure its nursing staff completed post-fall assessments after patients fell; failed to document the incidents in the nursing notes; and failed to ensure nursing staff implemented interventions as ordered, involving incidents with occurred with five geriatric patients.[25]  

October 9, 2018: FAILURE TO REPORT ASSAULT – The PADH identified an Immediate Jeopardy (a situation in which the facility’s non-compliance’s with one or more of Medicare’s requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for Haven Philadelphia’s failure to immediately report and investigate two incidents: one patient-reported allegation of sexual abuse and one incident of suspicious behavior by the same alleged employee, which was reported by another employee. There was no documentation that Haven fully investigated these allegations or reported them to the appropriate outside agencies. PADH also found that two employees—a behavioral technician and a registered nurse—who were required to have certification in use of restraint (“non-violent crisis intervention”) had no documentation of current training.[26]  

October 11, 2018: FAILURE TO DOCUMENT & REPORT SEXUAL ABUSE – PADH found that Haven Philadelphia failed to establish a budget for service quality assessment and performance improvement activities. This was requested of Haven by PADH in September 2018 but was never provided. Haven Philadelphia’s governing body (defined by the Centers for Medicare & Medicaid Services as “the persons legally responsible for the conduct of the hospital”) also failed to ensure that allegations of sexual abuse were reported as grievances; failed to ensure care in a safe setting for patients; failed to ensure policy was followed for reporting allegations of sexual abuse; failed to ensure incident report severity was properly documented; failed to ensure staff were properly trained; failed to ensure service quality data was collected, tracked and analyzed; failed to establish a budget for the quality program; failed to ensure staff completed mandatory training; failed to provide a safe physical environment; failed to maintain the annual tuberculosis prevention program; and failed to report a patient death to Gift of Life (organ donor agency). [27]  

December 5, 2018: PATIENT DEATH – The Arizona Medical Board reprimanded Haven Phoenix psychiatrist Thomas Opechowski, following investigation of a complaint about him prescribing an antipsychotic drug to a 72-year-old patient with Lewy Body dementia (Lewy Bodies are abnormal deposits in the brain of a certain protein which then interferes with thinking, mood, behavior, etc.). Opechowski failed to obtain informed consent for use of the drug. The patient was found in an altered state of consciousness, was diagnosed with brain damage and stroke and died five days later.[28]  

2019: The mother of an 18-year-old Idaho man reported in 2019 that her son was detained at Cottonwood on a mental health hold, though he’d gone there seeking, and was under the impression that he was going to receive, substance abuse treatment—which he did not. Cottonwood would not release him so that he could obtain substance abuse treatment. [29]  

2019: A 34-year-old woman reported to CCHR that following a December 2018 domestic incident in which she was badly beaten by someone who lived with her, she was involuntarily detained at Haven Dayton. Her report states that she was forced to take an antipsychotic drug and was both physically and sexually abused while detained there.[30]  

2019: PATIENT DEATH – A 2019 consumer review on the website Vitals.com of Cottonwood Creek psychiatrist Roberto Negron regards the deaths of a child who was under Negron’s treatment:  

“…when he was stating that the drug Paxil was one of his more commonly prescribed medication prescribed to children. He drugged my 12-yr-old daughter to death. Still have his own handwritten letter and his attorney’s correspondence with my attorney. According to him there was no valid proof that Paxil or Paxil withdrawal causes suicide et al. He is now the director of adolescent psychiatry. Let's look at the facts. His practicing psychiatry and drugging children and the increase in suicide rates in Idaho among adolescents has risen 10 fold since he’s been practicing.”[31]  

January 10, 2019: PATIENT NEGLECT – A TXDH inspection found that Haven Frisco failed to provide care in a safe setting by neglecting to provide 1-on-1 monitoring for a patient assessed as a high risk for falls. When the patient was placed on 1-on-1 (after two falls), Haven staff neglected to maintain it, resulting in the patient falling yet again.[32]  

January 18, 2019: The fiancé of a 26-year-old man reported to CCHR that Haven Frisco was detaining the man against his will, despite having filled out an “against medical advice” discharge application. The man had drunk alcohol and mildly injured himself. The report that CCHR received states that Haven’s head nurse and social worker admitted to the man’s family that they had not correctly followed protocol when admitting the man. The report also includes a statement from the man himself regarding the chaos, deception and incompetence he witnessed while detained there.[33]   

November 5, 2019: Michelle Crowder filed a personal injury lawsuit against Haven Behavioral Services of Albuquerque, and psychiatrists Anthony Holzgang and Rene Gonzalez, among others. As of January 28, 2022 the suit was ongoing.  

August 3, 2021: SEXUAL ASSAULT & FAILURE TO PROTECT – The family of a 79-year-old female patient with dementia filed a lawsuit against Haven Phoenix for failure to prevent a sexual assault by another patient. Phoenix Police stated that 42-year-old Jeffrey Mollett was admitted to Haven Phoenix on February 8, 2020 after being released from jail. Court documents state that Mollett was classified in hospital records as being a danger to others. Haven’s internal security video shows him walking the halls of the facility at 4:28 am and entering the elderly patient’s room. The family’s attorney stated that Haven failed to properly assess Mollett, otherwise he would have been more closely monitored by staff. Further, the attorney stated that Haven’s CEO admitted that Mollett should have been assigned to the facility’s secure unit, not a unit with vulnerable elderly patients with dementia. The case settled in August 2021. [34]  

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