Arizona
Center
for Disability Law
Mental
Health Team
Findings
from
Follow-Up
File Review & Site Visit
to
Vista
Care Residential Treatment
Center
March
31, 2005
Protection
and Advocacy System for Arizona
100 North Stone, Suite 305
Tucson, Arizona 85701
520-327-9547 (voice or TTY)
800-922-1447 (toll free)
520-884-0992 (fax)
3839
North Third Street, Suite 209
Phoenix, Arizona 85012
602-274-6287 (voice or TTY)
800-927-2260 (toll free)
602-274-6779 (fax)
Arizona Center for Disability Law
Mental Health Team
Findings From Follow-Up File Review & Site Visit
to
Vista Care Residential Treatment Center
March 31, 2005
________________________________________________________________________________________________________________________
I. Introduction
The Arizona Center for Disability Law (“Center”) is
the designated protection and advocacy system for persons with disabilities in
the State of Arizona. We advocate for the rights of persons with
disabilities to be free from abuse, neglect and discrimination and to have
access to housing, education, health care, employment and other services in
order to maximize independence and achieve equality. Specifically,
the Center is authorized by the federal Protection and Advocacy for Individuals
with Mental Illness (“PAIMI”) Act to investigate
incidents of abuse and neglect of individuals with mental illness. See 42 U.S.C. § 10801 et seq.
The Center presents the following findings and
recommendations based on a site visit and file review conducted in February
2005. This review follows a site visit
and file review the Center conducted in July 2004 and is part of an
investigation that stemmed from a complaint the Center received in the Fall of
2003 in which a parent alleged that a client had been physically abused by
Vista Care staff and that the treatment provided by Vista Care was
inadequate. Vista Care was also reviewed
by the Office of Behavioral Health Licensing (OBHL) in May 2004 which issued a
fine in the amount of $12,250.00 for identified program deficiencies. The Department of Behavioral Health Services,
Arizona Department of Health Services (“DBHS/ADHS”) stopped allowing its
contracted providers to admit children to Vista Care during part of 2004 but
resumed allowing admissions as of December 2004.
In February 2005, staff of the Center conducted a
six-month follow-up site visit and file review pursuant to the Center’s
findings letter dated July 22, 2004.
Four staff from the Center were involved in this review (two of whom are
attorneys and three of whom have graduate degrees in social work). The team reviewed a total of nine (9) files:
seven (7) of the young people were still receiving services at Vista Care, two
(2) of the files were for young people who had been discharged, six (6) of the
children were female, and three (3) were male.
The team also reviewed incident reports, grievances, police reports made
from Vista Care to the Cochise County Sheriff’s Department, the Parent
Orientation Guide, the Client Orientation Handbook, and a selection of Vista
Care’s policies and procedures.
The Center is pleased to report that substantial
improvements appear to have been made since the July 2004 visit including the
recruitment of local management that is responsive to the need for clinical
improvements in the program. Having said
that, the Center’s review indicates significant areas in need of
improvement. The Center is concerned
that Vista Care continues to rely too heavily on the use of physical
interventions, that staff do not consistently document incidents involving
physical interventions, assault, injury and self injury adequately, and that
staff do not consistently report incidents to outside agencies as
required. The Center is also extremely
concerned to see indications in the files of an over-reliance on psychotropic
medications. Additionally, the Center
urges Vista Care to take steps to improve its policies relating to issues of
Abuse and Neglect, Restraint and Seclusion, and to implement the principles and
processes adopted in the J.K. v. Eden settlement, such as ensuring that
Child and Family Teams are in place for all patients, as required by the
Department of Behavioral Health Services.
II. Clinical File Documentation Issues
Overall there appeared to be much improvement in the
documentation in the clinical files since July 2004. The files were clearly better organized and
maintained. Nevertheless, it was still
difficult to understand the sequence and chronological order of many of the
recorded events. Although most of the routine forms were found in files, the
Center is concerned that forms continue to be poorly completed with little
explanatory narrative. Many of the
narrative portions of forms were filled in with statements of such a general
nature that events and the course of treatment were difficult to follow. Our review also indicated that there is a
need for Vista Care to standardize the use of forms and make sure that all
staff are using the same up-to-date forms.
A.
Progress Notes
The Center was heartened to find that, in sharp contrast
with the previous review, almost all the files reviewed on this visit contained
daily progress note entries. However,
these daily progress notes were often extremely general and did not specify
which goals were being met, if any. It
is also problematic that in some files the Center found that a daily progress
note could be positive despite the existence of contradictory nursing or
therapy notes in the same file for the same date. There were more noticeable gaps in the
keeping of weekly team notes. Indeed,
some files were missing team notes for multiple weeks.
B. Therapy and Group Notes
In at least two files, the treatment plans failed to include
drug or alcohol treatment (AA or NA groups) as interventions despite the fact
that the information in the file demonstrated that such treatment was indicated
for the clients. In one of those files,
therapy and group notes were also
recorded inconsistently. Center staff
also frequently found that charts and forms were only partially completed. The Center further noted that, in at least
two files, therapy and group notes documented that clients were attending
meetings which were not listed on their treatment plan (e.g., AA or NA). At
least one file contained a reference to a client missing certain therapeutic
sessions despite the fact that those particular sessions were not listed in the
treatment plan. Additionally, goals, if
stated, were not clearly defined in many files.
C. Nursing Notes
In general, nursing note forms were regularly completed
and boxes were checked. However, there
was very little in the way of narrative or descriptive documentation in the
nursing notes. Additionally, some of the
files reviewed had missing admission information.
D.
Consent Forms
Consent forms concerning treatment and medication were
missing in many of the files. Documentation in some of the files suggest
that clients were given medication for many days or weeks before the
appropriate consent forms were signed by guardians or parents. Additionally,
when medication was changed, Center staff could not locate corresponding
informed consent forms. Two files lacked
the required consent forms signed at admission.
Moreover, many files which indicated that verbal consent had been given
to medication changes lacked the required follow-up documentation. In some cases, the client him/herself signed
the consent forms for medication change, but the guardian’s signature was
missing. In such instances, no follow-up documentation could be found showing
that the proper consent of the legal guardian had been obtained.
The Center strongly advises Vista Care to review DBHS’
Technical Assistance Document 8, Informed Consent for Psychotropic
Medication Treatment and Practice Improvement Protocol 1, The Use of
Psychotropic Medication in Children and Adolescents, and ensure that the
Vista Care program implements all aspects of these technical guidance
documents.
E.
Seclusion and Restraint Documentation
The Center noted two clear violations of seclusion and
restraint regulations. First, one file
that contained an incident report reflecting the use of both a chemical and a
physical restraint contained a doctor’s order only for a chemical restraint not
a physical restraint. The failure to
obtain a proper order for the physical restraint is a violation of Arizona Administrative
Code (“A.A.C.”) R9-20-602(C). Second,
another incident report which recorded the use of seclusion indicated a
violation of A.A.C. R9-20-602(I) where, during the use of seclusion, there was
one period of twenty-five minutes during which no staff monitored the patient
on a face-to-face basis.
F. Medication Administration
Nurses’ notes do indicate proper administration of
medication; however, no follow-up assessments seem to have been made in several
cases as to effectiveness of the doses or medications administered. There was
no indication that the clients themselves were asked about the effectiveness of
the medication they were taking, or if they could tell the difference in the
dosage. It was also unclear if the prescribing psychiatrist had met
face-to-face with the clients when prescribing the medication, although signed
notes were in the files.
G. Point Level
System
On a positive note, the clinical files reviewed contained
forms documenting points assigned under the level system for each day. Previously, such forms were not maintained in
the clinical files. Unfortunately, the
point level system remains unclear. Apparently,
points are given for certain actions or non-actions, but how these points
relate to individual goals is not explained. Also, it is difficult to ascertain
the connection between a client’s general conduct and his or her movement
between the levels. For example, in one
file the daily progress notes (which were consistently positive) did not appear
to correspond to the client’s movement back and forth between various levels.
III. Treatment Issues
Again, the Center noted improvement in the general area
of assessments and treatment. Nevertheless, the Center identified nine
categories of concerns relating to treatment issues in the files reviewed.
A. Pre-Placement Screening
In many of the files
reviewed, it is difficult to tell if the children actually meet published
criteria for admission to Vista Care. Information
sent by referring sources is limited and often there is no documentation of how
and when a diagnosis was made, what other treatment has been tried, or how the
child meets admission criteria. General
comments such as “runs away” and “difficult to deal with” are often cited as
evidence that a child is suitable for admission. A significant number of the children whose
files we reviewed had serious trauma histories, yet by admission Vista Care has
no specific treatment for children with post-traumatic stress disorder (“PTSD”)
or exposure to trauma. In addition, one
girl was admitted with “catatonic-like behavior,” and placed in a unit with
peers known to behave violently. This
led to numerous assaults against this young woman.
In contrast to our last
review, we did not find children with cognitive deficits that would have
created difficulties for them in this setting.
B. Evaluations and Assessments
Reviewers sometimes had
difficulty finding key assessments. In
one file, a significant evaluation from a previous doctor was filed in a
“miscellaneous” section. This evaluation
contained significant information regarding family history, diagnostic and
treatment history, and family background that should have been made known to
all staff working with this young woman.
Evaluations at Vista Care
are often poorly documented. At least
two of the files showed a change in diagnosis during the child’s stay at Vista
Care, without any documentation of why the diagnosis was changed. At least three of the files reviewed showed
children with “rule out” diagnoses which were kept intact throughout many
months of their stay at Vista Care. In one
case, two diagnoses that exist on a spectrum were included as “rule-outs”; in other words, if the child had one, they
would not be diagnosed with the other.
Yet both diagnoses stayed with this child. In another case, a child with a very
significant history of trauma and sexual assault carried a diagnosis of
“questionable PTSD” with no documented attempts to evaluate further.
C. Diagnoses
We found one record in
which the child had no diagnosis of substance abuse, yet the file recorded that
as the main reason for her stay at Vista Care.
One child was admitted with a diagnosis of depressive disorder Not
Otherwise Specified (“NOS”), yet assessments did not support the
diagnosis. This same child was
discharged from Vista Care on Concerta, without a diagnosis of Attention-Deficit/Hyperactivity
Disorder (“ADHD”). As mentioned above,
many children at Vista Care have significant histories of abuse, and some of
those children are at least given “rule out PTSD” as a preliminary
diagnosis. However, we did not see
documented any efforts to confirm or rule out that diagnosis, or the impact of
trauma on the individual.
D. Individualized Treatment
While improved over our
last survey, treatment plans still are not well individualized. Each child at Vista Care appears to get a
standard set of services, with the only individualization occurring (if at all)
in individual therapy sessions.
For example, at least two
of the files reviewed referred to behavior plans that were developed for the
child. However, we could not locate a
behavior plan in any file, nor did any file mention who developed or
implemented the plans. One child was
approaching the age of 18 and transition to the adult system, yet there was no
evidence of any activity to prepare her for that transition. On the issue of transitioning adolescents to
the adult system, the Center urges Vista Care to review and implement DBHS’s
Practice Improvement Protocol 7, Transitioning to Adult Services.
E. Medication
It was our impression that
girls at Vista Care receive more medication than boys, they are medicated more
quickly after their arrival, and they tend to be given more types of medication
than are boys. This may be an artifact
of our small sample, but it was notable and should be evaluated.
We again noted that many
children are given trazodone for sleep.
One child was prescribed this medication upon arrival because of “some
minor trouble falling asleep in the hospital” where she had recently undergone surgery. Another child, who denied sleep problems on
admission nursing assessment, was given trazodone to “fall asleep on
time.” In none of the charts reviewed
were any genuine sleep difficulties documented.
We are concerned that so many children are given a tricyclic
antidepressant for sleep rather than something more benign, such as Benadryl,
hot milk, or relaxation exercises at bedtime, if anything at all.
Another child, who was
noted to have a “sensitivity” to Risperdal on admission, was prescribed this
same medication three months later.
Orders indicated that she was to be watched for improvement of symptoms,
but not for drug reactions. The same
child told her doctor that her antipsychotic was too strong for her, and she
sometimes refused to take it. Her dosage
was not reduced for over a month after her first complaint.
Finally, at least one
child whose file was reviewed has no diagnosis or history of psychosis, yet
this child was prescribed antipsychotics.
F. Substance Abuse Treatment
The treatment Vista Care
provides for substance abuse issues appears to be attendance at 12-Step
meetings with occasional group therapy sessions focused on substance abuse
issues. One child was admitted with a
primary diagnosis relating to substance abuse, yet reviewers could find no
documentation that the child was actually attending AA/NA groups despite the
fact that such groups were included in his treatment plan. While the Center notes that improvements in
Vista Care’s documentation has made it easier to track attendance at 12-Step
meetings, the lack of documentation in one of the nine files reviewed suggests
this may be an area that deserves Vista Care’s continued attention.
Additionally, at least
some of the files indicate “packets” to be completed and processed in therapy
sessions. If these are part of substance
abuse treatment that must be completed before discharge, it would be helpful if
the files were clear about the specific requirements and when/if they are
completed.
G. Trauma Treatment
We are relieved to hear
that the program does not intend to continue to rely on staff with only
bachelors-level training to provide therapy but, rather, that Vista Care
intends to hire trained, professional therapists with masters level
credentials. Moreover, the Center was happy to learn that Vista Care has plans
to engage one or more therapists who have experience treating trauma. We strongly encourage you to do that as soon
as possible, since so many of the children at Vista Care have significant
trauma histories. Whether or not a child
meets criteria for a diagnosis of PTSD, some attention should be given to the
effects of traumatic experiences.
As noted previously,
initial assessments often take note of whether a child has had traumatic
experiences, though the current assessments are not thorough in defining the
range of experiences that should be assessed as trauma. Some children start their treatment with
“rule out PTSD” as part of their Axis I diagnosis. We found no evidence that further assessment
or treatment is conducted to either “rule out” or confirm the diagnosis, nor to
treat the effects of trauma.
The current milieu does not appear to understand
trauma or to provide support so children can learn healthy coping skills rather
than the maladaptive ones they used to survive their trauma. Some specific
problems with treatment included an inability to effectively address trauma
issues. For example, one young woman
with a significant history of sexual assault was subjected to a therapy session
in which she was told that it was “unfair to men” that she didn’t trust
them. Another young woman with a trauma
history engaged in some minor self-injury, and as a “consequence” was not
allowed to participate in equine therapy.
When behaviors are learned by children who use them to survive trauma,
it is not sufficient to try to “extinguish” those behaviors in the same way one
would try to extinguish any other undesirable behavior. Staff should be working to understand the purpose
of the behavior and helping the child find better ways to meet those
needs. Simple denial of privileges will
often escalate the problem.
As a further example, one
child was admitted with an extensive history of trauma. This child was put on a unit with young women
who had a history of violent behavior.
She quickly became a target, and was assaulted multiple times. The staff, who agreed to have a BHT stay
close to protect her, clearly failed to protect her from further assault. At
least on one occasion, therapy notes refer to her “guilt and anger toward
‘perceived’ mistreatment,” without clearly acknowledging the fact that the
child was being routinely targeted.
Allowing continued assault and minimizing its existence both contribute
to the trauma this child has already experienced.
H. Level System
It is still not completely
clear how determinations are made to move a child from one level to
another. In at least one file, the daily
progress notes seemed almost uniform in regard to the child’s behavior, yet
they did not correspond with the ups and downs in his movement between
levels.
I. Discharge Criteria
Criteria for discharge are
not clearly documented in the file, and not articulated in a way that could be
easily understood by a child. In fact,
one child who was interviewed was asked what goals she needed to meet to
successfully complete the program. She
could not answer this question. She did,
however, say that she would be leaving soon because “they don’t know what to do
with me.”
Several files contained
references to compliance with a specific percentage of the treatment plan. This can be very subjective. It might also allow a child to excel in one
area and yet entirely ignore another problem area. Some discharge criteria appeared to be
“moving targets,” changing as the child approached discharge readiness. We recommend that discharge criteria should
be concrete, understandable by the child, and stable, not changing throughout
the child’s stay. Each child should know
from the beginning what they are expected to achieve in order to successfully
leave Vista Care.
IV. Incident Reports and
Coercion Concerns
Center staff reviewed a file
of incident reports for the period from July 1, 2004 through January,
2005. We remain concerned that Vista
Care is not providing the Center with all of the reports it is mandated to
provide. We are encouraged to hear
administrations’ plans to pursue zero restraint and seclusion; however, we are
also concerned that necessary steps have not been taken which would further
reduce the use of physical interventions.
A. Under-Reporting of Reportable Incidents
It is, of course,
difficult to know what incidents have not been reported and what facts may be
missing from existing reports. Records
reviewed suggest that Vista Care has not been providing the Center with all
incident reports of the type that Vista Care is mandated to provide to the
Center, pursuant to A.A.C. R9-20-202. As
a Level 1 RTC, A.A.C. R9-20-202 requires Vista Care to report the following
incidents to the Center within one working day:
1. Any client death.
2. Any medication error, adverse reaction to a
medication, suicide attempt, or self-inflicted injury that occurred on the
premises or during a licensee-sponsored activity off the premises that requires
medical services or immediate intervention by an emergency response team or a
medical practitioner.
3. Any suspected or alleged abuse, neglect, or
exploitation of the client or a violation of the client’s rights under A.A.C.
R9-20-203(B) or (C).
4. A physical injury that occurred on the
premises or during a licensee-sponsored activity off the premises that requires
medical services.
Please note that incidents
involving suspected or alleged abuse, neglect, exploitation, or rights
violations must be reported regardless of whether any medical care was
required. Further, the array of rights
listed in A.A.C. R9-20-203(B) and (C) is extensive. For example, incidents of peer on peer
violence, particularly where there are multiple incidents against one client,
should be reported to the Center under this provision. Additionally, whether or not Vista Care finds
that a client grievance is substantiated, whenever a client makes allegations
of abuse, neglect, exploitation, or a rights violation, such reports should be
forwarded to the Center. The Center
notes that at least one of the grievances reviewed (and arguably more) related
to an allegation of abuse of a client by a BHT.
Such an allegation should clearly be reported to the Center.
The applicable rules
provide imperfect guidance regarding which injuries require medical services
and/or immediate intervention by an emergency response team or medical
practitioner. In light of the
potentially complex questions entailed, the Center encourages Vista Care to err
on the side of making reports rather than risk under-reporting. For instance, a large percentage of
self-inflicted injuries, almost by definition, will require immediate
intervention upon discovery. The Center
encourages Vista Care to report such incidents routinely. Additionally, if an injury requires medical
staff to do more than cleanse a simple scratch and/or if the “nurse treatment”
box is checked on the incident reporting form, the Center encourages Vista Care
to send such reports to the Center.
On a positive note, Center
staff are pleased to see that the numbers of reportable incidents appear to
have been decreasing in recent months.
B. Unclear Incident Reports
Many of the reports
reviewed raised questions among the reviewers about medical treatment. For example, a number of reports indicated
children banging their heads against walls or floors, yet there was no mention
of whether they were examined by a nurse or other medical staff. Another example took place on November 26,
2004, when a client hit and broke some glass, yet there was no mention of any
medical inspection or whether she had been injured. This again raises the question about whether
the number of incidents reported or required to be reported is correct.
In addition, one incident
recorded a pair of scissors missing after an activity. A girl went into the bathroom and came out
with her hair cut. When asked where she
was hiding the scissors, she said, “in my paints.” Immediately following this notation was “End
of report.” Clearly, the staff should
have recorded the completion of this incident and the ultimate safe retrieval
of the scissors.
Also, the completion of
the incident reports is inconsistent, and the forms are not all the same. We encourage administration to standardize
the form and make sure staff is trained on proper completion and reporting.