Regulators find Universal Health Services psych hospital deficient again

May 30, 2014

Three months after state regulators allowed a Brookline psychiatric hospital to start accepting new patients again, federal investigators found deficiencies with psychiatric evaluations and treatment plans, problems they said may have hindered patients’ recovery.

The federal report, based on a February inspection, concluded that Arbour HRI failed to provide active treatment for at least four patients. The patients, whose diagnoses included bipolar disorder and paranoid schizophrenia, spent many hours without structured activity, the report said.

Instead of attending group therapy, they spent many hours sleeping or wandering around the hallways, inspectors said. When investigators asked one nurse about the lack of alternative treatments, she disagreed.

“Sleep is an alternative,” she replied.

Massachusetts regulators prohibited the hospital from accepting any patients in November, citing unsafe conditions. When they allowed admissions to gradually resume two weeks later, in early December, mental health officials said Arbour HRI was working to bring the “culture of care’’ up to “our high standards.’’

Yet in February, inspectors for the federal Centers for Medicare & Medicaid Services found serious shortcomings in the quality of treatment at the 66-bed hospital in Brookline. Soon after, Arbour HRI’s chief executive, Patrick Moallemian, left his job.

Arbour spokeswoman Judith Merel would not disclose the reason for his departure. Despite the federal findings, she said, patients at the hospital received good treatment.

The federal investigators’ report, which Medicare provided to the Globe in response to a public records request, details the latest in a series of problems at Arbour Health System hospitals and clinics resulting from poor training and understaffing.

One Tuesday afternoon during the February inspection at Arbour HRI, there were 11 patients in a unit for those diagnosed with both mental illness and a substance abuse disorder. Only three were in therapy. Eight were found in bed. Staff members often wrote in the medical records that patients were offered “educational materials’’ as an alternative, but they did not specify what the materials were or how the patients responded.

Inspectors also faulted the hospital for not including patients’ strengths in psychiatric evaluations, which is information that could help psychiatrists decide upon the best approach to therapy. Treatment plans consisted of boilerplate language and were not tailored to individuals, investigators found.

In the improvement plan it submitted to Medicare after the February inspection, Arbour said it hired consultants, educated staff about proper procedures, and brought in a new chief executive, who started in April. The hospital said the board of advisers would take a more active role overseeing the hospital. A press release on the hospital’s website said that William Zella, a licensed psychologist, is now chief executive.

In a written statement to the Globe, Merel, Arbour’s spokeswoman, said that despite Medicare’s findings, Arbour HRI patients “received appropriate and individualized, effective care and treatment.’’ She said that patients may not be able to attend group therapy for clinical reasons, and that in those cases “alternatives such as individual activities or therapies are offered.’’

The hospital’s electronic medical records did not allow staff members to record specific treatment plans for individual patients, Merel said, but the system has since been updated to make that possible.

Arbour Health System operates five psychiatric hospitals and 12 mental health clinics in Massachusetts. Its for-profit parent, Universal Health Services, is a publicly traded company that earned more than $500 million last year and has staked its future largely on expanding in the behavioral health care market.

Arbour HRI in particular has been very profitable. The hospital earned a 32 percent profit in 2012, compared with an average 9 percent earned by other non-acute care hospitals in Massachusetts, according to the most recent state reports. Nearly 85 percent of patients at the hospital are covered by the federal and state Medicare and Medicaid insurance programs, meaning that many are poor, and that most care is paid for by taxpayers.

Frank Barnes, a longtime mental health worker at the hospital and a union representative for 1199SEIU, said the problems at Arbour HRI reflect the culture of the administration.

“The emphasis wasn’t on the quality of care,” he said. “It was on increasing income.’’

Staff members have filed numerous complaints with hospital leaders and regulators about a lack of security personnel; inadequate staff; and patients not having enough towels, blankets, and food at night, he said.

State regulators have identified staffing problems elsewhere in the Arbour Health System, including allowing therapists without required training or supervision to treat patients at outpatient clinics. Arbour Hospital in Jamaica Plain was found to have too few nurses during four consecutive inspection cycles and was cited for staff failures related to two questionable deaths.

State inspectors made a surprise visit to Arbour HRI in October, after receiving a report about a female patient being forcibly searched, an incident that state Mental Health Commissioner Marcia Fowler described in an interview as “a very serious human rights violation.”

Inspectors identified a range of problems, including dirty conditions and untrained or inexperienced staff, prompting the state to stop admissions for two weeks. When the Department of Mental Health allowed the hospital to start accepting patients again in December, licensing director Lizbeth Kinkead said in an e-mail, regulators were “satisfied that Arbour HRI is working to ensure that the changes are made, that the culture of care is up to our high standards, and that these are visible throughout the hospital.”

Federal inspectors also visited the hospital in December after receiving a complaint. They found numerous problems, prompting the in-depth review in February.

When asked why the state cleared Arbour HRI in December, only to have federal inspectors find serious deficiencies three months later, state officials said they were working intensely with the hospital during those months to spur improvements. State regulators visited Arbour HRI and met with staff 11 times between Dec. 10 and March 20, they said. Last month, the state allowed the hospital to open all units to new patients — with assurances of adequate staff, medical coverage, and group programming.

Massachusetts Health and Human Services Department spokesman Alec Loftus said that in addition to the Medicare efforts, Arbour has made improvements.

“Many of the ongoing issues identified by DMH in site visits and discussions with the company’s leadership have resulted in improvements to the quality of care at the facility,” he said in a written statement to the Globe. “We are encouraged by the decision to make leadership changes at the facility, which is a visible sign of its commitment to change.’’

Representative Elizabeth Malia, a Jamaica Plain Democrat and chair of the Joint Committee on Mental Health and Substance Abuse, said Arbour takes many chronically ill patients with very challenging conditions. She said it probably makes more sense for the state to work with the hospital than shut it down.

“You can pull their license, but then what?” she said. “Where do these folks go? You can’t just put people back onto the street.’’

Barnes said he is hopeful the hospital will improve under Zella, the new chief executive. Zella, he said, has hired more nurses and mental health workers and has instituted policies to more carefully evaluate patients for serious medical problems. Those patients may not be able to be safely cared for at Arbour HRI, he said.

“We’re very pleased with the changes he’s making,’’ Barnes said. “There’s a long way to go."

Source: Liz Kowalczyk, "Regulators find Brookline psychiatric hospital deficient again," Boston Globe, May 30, 2014.