State and federal regulators investigate patient care problems in Universal Health Services psych facilities

November 12, 2013

Pennsylvania health officials in 2011 temporarily stopped a mental health center from admitting children or teens after they found poor conditions, excessive use of physical restraints, and too few people caring for patients, according to state records.

In a psychiatric hospital in Chicago the same year, investigators found that violence was “an everyday occurrence,” fueled by understaffing.

And when regulators in North Carolina last year took steps to revoke the license of a residential treatment center after violence at the facility, they cited, among other things, incompetent clinical staff.

All three facilities were owned by Universal Health Services, the largest operator of freestanding psychiatric centers in the United States. Universal has a history of staffing problems at its hospitals around the country, but this record has rarely factored into reviews by state regulators — including in Massachusetts.

The company runs seven inpatient facilities and 13 clinics in the state, under the name Arbour Health System, which in recent years have been repeatedly cited for not having enough nurses and for allowing unlicensed or unsupervised workers to treat people.

Massachusetts health officials have not examined whether Universal’s corporate practices might have contributed to violations by Arbour, which owns 1 in 5 psychiatric hospital beds in the state and serves large numbers of poor and disabled people.

“Someone should be saying, ‘What’s their track record elsewhere?’ ” said Christine Griffin, executive director of the Disability Law Center, a nonprofit group that represents people with mental illness.

The federal government may now be undertaking a broader review. The facilities in Pennsylvania, Illinois, and North Carolina, along with eight more of Universal Health Services’ nearly 200 psychiatric centers, have received subpoenas from the inspector general at the Department of Health and Human Services, who investigates fraud or abuse of government health care programs, according to the company’s latest quarterly report filed with the Securities and Exchange Commission. None of the facilities are in Massachusetts, but two in Florida also are being investigated by the Department of Justice criminal fraud section.

It is not clear what prompted the subpoenas, most of which were issued in February. A spokesman for the inspector general declined to comment. Several of the facilities under investigation have been cited in recent years for violations similar to those found at Arbour, according to state records.

Universal Health Services Inc. is a public company that earned about $443 million last year and has tied its growth to expanding in the behavioral health business. In 2010, the company paid $3.1 billion to buy Psychiatric Solutions Inc., a major provider of inpatient psychiatric care that owned three of the hospitals receiving subpoenas this year.

Psychiatric care is widely seen as underfunded, with advocates and industry leaders frequently calling for higher payments from insurers. But Arbour’s Massachusetts hospitals last year reported profits of between 15 percent and 32 percent, according to company reports filed with the state. By comparison, two other large freestanding psychiatric hospitals in Massachusetts, for-profit Bournewood Hospital and nonprofit McLean Hospital, reported single-digit surpluses.

In an interview in August, state Mental Health Commissioner Marcia Fowler said Arbour Health System is “of great value to the Commonwealth,” because the hospitals care for some of the most difficult patients in the state’s care. Arbour facilities include specialized units for patients who may be violent, people with developmental disabilities, and children and teens in crisis.

The company’s disciplinary record in Massachusetts did not raise red flags, Fowler said. She declined, through a spokesman, to be interviewed for this story or comment on whether her agency should consider Universal’s national record when reviewing care at Arbour.

Arbour spokeswoman Judy Merel refused Globe requests to speak with company executives. Merel said in an e-mail that Arbour hospitals, like all Universal facilities, regularly “assess several key patient safety and quality metrics to ensure we are providing the highest quality care and treatment to our patients.”

Universal’s central clinical services office also tracks quality measures, she said, and hospital staffing needs are monitored to maintain “therapeutically appropriate levels.”

The Globe reported in June Arbour allowed therapists who lacked the required training or supervision to treat patients at outpatient clinics that serve large numbers of poor people. The family of a teenager who died after being treated at a Lawrence clinic has filed a lawsuit alleging that Arbour fraudulently billed the state Medicaid program for care provided by unqualified workers. The suit does not blame the death on the clinic’s care.

Separately, Arbour hospitals have been cited repeatedly for staffing issues. In four consecutive inspection cycles, Arbour Hospital in Jamaica Plain was found to have too few nurses. Two units were noted in 2009 as having nursing levels “well below a reasonable and safe standard.” The same hospital was cited for staff failures related to two questionable deaths.

After each violation, the state approved Arbour’s plan of correction with little acknowledgment that past problems in the Arbour system had recurred despite promises to fix them.

The regulatory system is not designed to look for patterns, particularly across state lines, said Ira Burnim, legal director of the Judge David L. Bazelon Center for Mental Health Law in Washington, D.C. Oversight often is handled “incident by incident, review by review,” he said, which is ineffective at addressing systemic issues.

Universal’s hospitals go by different names in different states, which has helped it keep a low profile. Several national mental health advocates interviewed for this story were unfamiliar with the company.

Ron Honberg, the legal director at the National Alliance on Mental Illness, a patient advocacy group, first said he had never heard of the company, then realized that Universal Health Services is a significant donor. The company gave about $85,000 in February to support family education programs and a fund-raising event, he said.

“I certainly think that we need to be aware and concerned that there are broad-based systemic allegations about a particular sponsor,” he said, but he cautioned that, often, what happens at one hospital is not reflective of operations in a system overall.

One state has examined Universal Health Services’ broader operations. After reports of problems at Hartgrove Hospital in Chicago, the Illinois Department of Children and Family Services in 2010 asked experts from the University of Illinois at Chicago Mental Health Policy Program to review the facility.

Investigators documented 100 incidents of violence and abuse in six months. In one incident, a boy’s arm was broken when staff members improperly restrained him and he was not given medical care until the next day. The team found that the hospital regularly admitted too many people and was understaffed to handle even the permitted number of patients.

The group looked at Universal Health Services hospitals in a dozen other states that had been cited by regulators, including Massachusetts. Problems with staffing and poor quality of care came up in each.

Because the issues were repeated from facility to facility, the team wrote, Illinois regulators should not simply allow the company to submit a plan promising to fix problems at Hartgrove, a standard response to state citations. “That is simply not good enough, especially in light of compelling data that promises from Universal Health Services generally cannot be relied upon in good faith,” the authors wrote.

Merel said in an e-mail that Universal disputes the report’s findings. She called Hartgrove “one of the finest psychiatric hospitals in the region.”

The Illinois Department of Children and Family Services in 2011 issued an “intake hold,” meaning it stopped sending state wards to Hartgrove. Two other Universal hospitals in Illinois, both previously owned by Psychiatric Solutions, have intake holds in place. The department stopped sending patients to a fourth Universal hospital this year, after investigators documented violence and inadequate staff training. Two of the hospitals, including Hartgrove, received subpoenas from the Office of the Inspector General.

This is not the first time that office has taken a hard look at a Universal facility. In 2010, federal investigators worked with Virginia officials to bring a case against one they said falsified records and billed Medicaid for care it never provided.

Keystone Marion purported to be a residential treatment center for boys ages 11 to 17, the complaint said, but “in fact, it was operated as a juvenile detention facility.” The case alleged workers provoked boys to justify extending their stay so the facility could continue receiving Medicaid payments and the company billed for treatment provided by unlicensed or unsupervised therapists.

Universal closed the facility andagreed to pay nearly $7 million to settle the case. It did not admit wrongdoing. Merel said Universal stands by the “high quality care and treatment” the center provided.

Source: Chelsea Conaboy, "National reviews of centers rare in mental health," Boston Globe, November 11, 2013.