Strategic Behavioral: Colorado Moving to Revoke License of Clear View Behavioral Health

June 25, 2019

JOHNSTOWN, Colo. – The state of Colorado on Monday moved to revoke the psychiatric hospital license for Clear View Behavioral Health in the wake of months of reporting by Contact7 Investigates and investigations by multiple state and federal agencies and the attorney general’s office.

State officials believe it is the first time that the state has moved to revoke the license of a hospital operating in Colorado.

The facility received a 32-page notice from the Colorado Department of Public Health and Environment on Monday giving administrators notice that their license had been revoked, which Denver7 received through an open records request on Tuesday. The administrators will have 30 days to respond to the revocation action, during which time the facility will still be allowed to see patients.

Clear View Health Behavioral Health CEO Sharon Pendlebury said in a statement Tuesday that the facility was “disappointed” by the release and in discussions with the state over how to address the issues outlined in the notice.

In more than seven months of reporting, more than five-dozen patients, family members and employees – both current and former – raised concerns about the quality of care inside the behavioral health center, and former employees told Contact7 Investigates they had witnessed multiple “questionable deaths” at the 92-bed facility located about an hour north of Denver.

Specific accusations include decisions by senior leadership to keep patients longer than medically necessary, failing to provide required therapy, patients' items being stolen or going missing, short or limited doctor visits and improper billing of private insurance, Medicaid and Medicare.

In the notice to Clear View obtained Tuesday, the state says that Clear View has been “unable to sustain compliance with state licensing and/or federal certification requirements” and has been cited by CDPHE for 85 deficiencies. The notice also says that the facility “has been out of compliance for eleven (11) months” and that administrators “have failed to demonstrate evidence that the Facility’s compliance is improving.”

The investigations

Since at least February, the Colorado Attorney General, CDPHE, Colorado Department of Behavioral Health and the Offices for Medicare and Medicaid Services have been conducting independent investigations into the facility and those accusations.

Days after the initial Contact7 Investigates report on the facility aired in January, the state conducted a surprise inspection, the results of which were detailed in a report obtained by Contact7 Investigates last month. It has since conducted a second surprise visit.

State inspectors placed Clear View on an “immediate jeopardy” designation early this year – the most serious designation the state’s Department of Public Health and Environment can place on a facility. That designation was given, according to the state, because Clear View failed to maintain a sanitary environment throughout all patient care areas and the kitchen. The state also identified another “immediate jeopardy finding” for the facility’s failure to properly investigate patient falls and suicide attempts.

The report issued as a result of the January inspection confirmed concerns exposed by those whom Contact7 Investigates spoke with and interviewed over the past months: that there was not a safe setting for all patients at the facility.

“Specifically, the facility failed to ensure patients did not have access to contraband; failed to increase levels of observation after suicide attempts; failed to monitor patients who required increased observation; failed to discharge patients in a safe manner; and admitted patients with unstable medical conditions who met exclusionary criteria. These failures resulted in negative patient outcomes and potentially contributed to a patient’s death. Additionally, these failures resulted in patients having access to heroin,” the January report stated.

Larimer County Coroner Dr. James Wilkerson told Contact7 Investigates there was reason to wonder if the facility contributed to the death of a 47-year-old man, Tibor Hetei, who was in care there and who received a “B52” cocktail of tranquilizers hours before he died. A former facility tech said a different death at the facility which they witnessed was, in their mind, “highly preventable.”

The report from January, released last month, details a third death the state has questioned. The report says a patient received medication for a kidney injury that was known to have side effects, which the report says “potentially contributed to the patient’s death.”

Colorado Attorney General Phil Weiser told Contact7 Investigates last month that his office, along with the Larimer County district attorney, had an ongoing investigation into the facility and the death of the 47-year-old man.

"We tell every company when we're looking at what you're doing we need you to take responsibility. We need you to work with us to admit what happened,” Weiser said, also thanking the dozens of insiders, patients and family members who have talked to Contact7 Investigates. "We appreciate that the people are coming forward. They deserve to be heard. We are doing our best to not let this sort of thing happen again."

Just weeks before Weiser confirmed the investigation, in early May, the state announced that the federal Centers for Medicare and Medicaid Services (CMS) had placed the facility on a 90-day termination track to remove their federal certification. Tuesday’s notice notes that the termination tract began on March 26 and ended Monday, June 24.

Additionally, the Colorado Department of Public Health and Environment’s Complaints and Occurrences Section Manager Peter Myers said that Clear View had been placed on a corrective conditional license on Feb. 1, which requires “additional oversight by an outside consultant and the department to improve patient care,” Myers said.

He said at the time that the CDPHE was one of four state agencies investigating the facility and confirmed the state has been conducting on-site surveys since last year.

"Clear View reported the 2017 death when it occurred, and the department immediately conducted an off-site investigation. It was the beginning of what has become our long-term involvement with Clear View Behavioral Health. Between the date of the patient's death and the Channel 7 interview earlier this year, the department conducted five (5) on-site surveys," Myers said in a statement at the time.

The parent company of Clear View, Strategic Behavioral Health, confirmed in mid-March – amid the investigations by Contact7, the state and feds – that CEO Rick Harding resigned. He was the sixth person to leave the facility’s senior management team since Contact7’s first report in January. Others who left were the facility’s chief operating officer, chief financial officer, director of business development and two other senior managers.

Third visit uncovers more, continuing deficiencies

The facility could avoid the 90-day termination action by CMS if it corrected its deficiencies, which were detailed in the notice, Clear View was told when it first was told of the window. But the notice to Clear View made clear that the only way for investigators to determine if the deficiencies had indeed been corrected would be through another unannounced visit.

That visit came during the last week of May, and the investigation was complete by May 29, according to the revocation notice. The state found Clear View was still not meeting the conditions set forth under the conditional license and had not corrected many of the issues it was cited for in the first place.

“[T]he Department determined that Licensee/Respondents had not achieved compliance when it went to conduct the third revisit for this Event ID,” the revocation notice says.

The notice said Clear View failed to track contraband properly and did not properly observe those under observation for suicide attempts, among other things.

“These failures resulted in multiple suicide attempts by patients who had been admitted to the Facility for risk of attempted suicide,” the notice states.

It also says that the facility broke its own, along with the state's, rules for how it accepted and admitted patients based in its own ability to meet those patients' needs.

In one instance, according to the notice, that failure to not admit certain patients possibly contributed to a patient’s death after the patient arrived in an “unstable medical condition” which “potentially contributed” to their death.

Thirdly, the state says in its notice, Clear View failed to re-evaluate discharge plans for patients of concern.

One patient’s medical record showed multiple conversations that staffers documented in which both the patient and her family said they felt unsafe having her around the family because of a history of sexual abuse of a sibling and violence toward family members and animals.

“Physician #8 stated he could find nothing which indicated staff had followed Facility policy to ensure a safe and appropriate discharge for Patient #10,” the notice says.

Another patient, a legally blind wheelchair-bound man who had attempted suicide, was to be discharged to a homeless shelter in Pueblo, according to the notice, which he voiced concerns about on multiple occasions. But investigators found that some of the staffers had not even contacted the shelter to see if it could provide the needs of the patient.

Another case manager told investigators “she was working to create a discharge process because there was currently no standard discharge process in place at the Facility,” according to the notice.

In total, the notice says, three of 13 discharge records reviewed on Feb. 1 found that patients were discharged without a safety plan in place and without a safe place to go.

The notice says that the CDPHE has determined that Clear View and its administrators “are not fit to provide psychiatric hospital services” and have asked a judge to revoke Clear View’s psychiatric hospital health facility license for “failure or refusal to comply with statutory and regulatory requirements for the psychiatric hospital license type.”

What comes next?

Following Contact7’s first report on Hetei’s death in May, attorneys hired by Clear View sent a letter demanding all stories be removed from our website, that the raw interviews be published, and concluded: “Lastly we encourage you to review the above-reference Story (and others that aired previously) and take whatever other action you deem appropriate to address Mr. Kovaleski’s unethical, inaccurate and unbalanced reporting.”

Denver7’s lead attorney declined to adhere to the demands made by Clear View’s attorneys and responded, in part: “The Station’s reporting on Clear View is true, substantially true and is supported by extensive investigative records.”

The notice stipulates that Clear View and the other respondents file a written answer to the notice within 30 days of receiving it. If they fail to do so, a default decision could be entered that would make the revocation final.

Pendlebury, Clear View’s CEO, said in the Tuesday statement the facility was working with the state:

“At Clear View Behavioral Health, we are committed to providing safe, high-quality care to our patients. Over the last several months, we have made a number of improvements in our processes to address concerns raised at the beginning of the year by the Colorado Department of Health.

“The Health Department approved our improvement plan and we have been working collaboratively with them as we have implemented it. We were disappointed by the notice we received yesterday, and are in communication with Health Department to determine how we can address their concerns so that Clear View can continue its vital role of providing much-needed behavioral health treatment to the people of our region.”

Source: “Colorado moves to revoke license of Clear View mental health facility after repeated investigations,” Denver7 investigations, June 25, 2019. URL: https://www.thedenverchannel.com/news/investigations/clear-view-investigation/colorado-moves-to-revoke-license-of-clear-view-mental-health-facility-after-repeated-investigations