Mendocino County mental health providers were found in violation of multiple state regulations according to a report from a Center for Medical and Medicaid Services (CMMS) recertification audit. Violations ranged lack of coordination of client case files, including one client found dead, to improper use of facilities for drug testing, staff listed in job positions for which they lack qualifications, failure to ensure compliance with fire, biohazard, and other safety regulations, and other issues associated with community mental health centers

The report comes from an unannounced recertification audit of Mendocino County’s Behavioral Health and Recovery Services providers (ASOs) conducted during September. At the time of the audit, then county Mental Health Director Tom Pinnizotto and HHSA Director and current interim Mental Health Director Stacy Cryer said the inspection was a routine facilities safety check for services the county did not provide (a Partial Hospitalization Program), although Cryer could not recall a similar inspection in the 7 years prior. This CMMS inspection audit is part of recertification requirements for patients whose care is billed to Medical and Medicaid,

and the report serves as a “statement of deficiencies,” including a lack of Partial Hospitalization Program. Typically after such findings, a “plan of correction” with timeline is provided in response from the county, although county staff could not specify when the report was received, or if and when a response would be provided to CMMS. The inspection occurred September 22 – 28, 2014 at facilities managed by Mendocino’s ASOs in Ukiah, including a adult access site run by Ortner Management Group (OMG) and subcontractor Integrated Care Management Solutions, where the majority of violations appear to have occurred, and one run by youth services provider Redwood Quality Management Company (RQMC). The audit was conducted by two nurses who visited multiple facilities and conducted a random survey of 10 outpatient client records, and also conducted follow-up inspections and interviews. Numerous violations found included both specific issues with compliance for site and client protocols, as well as violations which point to broader problems with contractor communication and coordination of care across providers for each client.

When first contacted for a response to the CMMS audit, HHSA Administrator Dora Briley told TWN when asked for comments that Cryer was not available but had said that “98 percent of violations had been addressed” and “she wanted to make sure it was understood that the service providers subcontract out with other providers.” After a request for further specifics, Deputy Director of Mental Health Jenine Miller said the county was “right now in the process of investigating the deficiencies found, and working with the ASOs to make sure they are being corrected.” Advertisement Miller said the county was “unaware” of these problems previously and plans to investigate further to determine if a plan of correction is necessary from the ASOs. According to Miller, the county performs annual checks on the facilities, although state regulations only require inspections every three years, and staff utilize other oversight mechanisms such as surveying client charts, billing, records inspections, and staff spot checks to ensure ASOs are following protocols. Miller said during the last county inspection of the adult Ukiah facility no issues had been found, although she could not clarify when that inspection was by press time. Coordination and Communication Violations One of the recurring violations noted by CMS inspectors concerned a lack of coordination of client services between case managers, primary care physicians, and contracted staff, as well as a lack of documentation concerning what services were actually provided to the clients.

Such violations can lead to problems with patient care if case managers are unaware of client medications, or when plans for patient care are not followed due to lack of coordination with available services or between different client care providers. The report states “the center failed to maintain a system of communication that assures the integration of services, when documentation that communication between contracted adult mental health services and the client’s outside healthcare providers did not occur.” This lack of communication meant that documentation of client medication, contact with case management, attendance of workshops, and in one case, the failure to provide followup care as prescribed——which could have contributed to the death of a client, referred to as “Client 10” months later—were not properly included in case management files reviewed during the audit. In the case of Client 10, case files failed to document the client’s attendance at multiple rehabilitative sessions and dual-diagnosis workshops and the documentation of informal or “non-billable” contact with case manager. In Client 10’s case files, one staff member noted care appeared to have “fallen off a cliff,” and although staff said the client had received services, many reported contacts were not documented.

In addition, Client 10’s case manager stated to auditors that “there was little collaboration with the centers contacted adult services; that she was unaware what services were available.” Client 10 was also found to have received care from a Psychiatric Nurse Practitioner who had been listed as a Psychiatrist at the client’s mental health clinic. Staff also failed to document the discharge of the client after staff were notified of his death while still under care, with Client 10’s name remaining on active client lists. Meanwhile, other clients sampled were not found on attendance or active client lists despite being currently under active care. Staff also stated different policies to auditors—such as a lack of requirements concerning case management visit frequency—that differed from client care plans documented in client case files.

Organization, Infection, and Safety Violations One notice of violation was for failure to maintain an accurate list of current clientele, for which no explanation was provided by audited staff. Clients were found to be listed inaccurately on active or inactive client lists, and case files found to lack adequate documentation of services provided. Such practices can lead to inaccurate billing practices as well as inadequate client care management.

In a site inspection of a non-county certified mental health access facility, auditors found drug testing and urine sampling kits in a medication room, a location which the county had not authorized to conduct such tests. Staff could not provide an explanation of why such materials were stored at the site, and confirmed that no such testing was authorized to occur at that location. Unsecured medications were also found during the site inspection, with staff acknowledging to auditors that said medications were not being properly handled. Staff could not clarify the location of medication disposal logs at the center, and also responded that medications were not administered at the facility.

Auditors also found improper management of “sharps” or used injection needles, which can present a biohazard to both staff and clients at the site. Medications were found to be mixed in with the needles and needles found uncovered. Staff responded that the needle container “needs a lid,” and other staff stated that there was no contractor in place to properly dispose of use needles as required by state regulations. The audit also found a failure to comply with fire safety codes, with lack of adequate fire extinguishers to ensure public safety in the facility. The full report can be found at http://bit. ly/1IEXtVF