Pattern of “life-threatening” prescription errors at Mind Springs Health, investigation finds
By Christopher Osher, Colorado Springs Gazette and Susan Greene, Colorado News Collaborative
A pattern of “severe, life-threatening” prescription errors by the troubled mental health center responsible for treating 10 Western Slope counties put patients at risk, according to the findings of an investigation that state agencies withheld from the public for more than nine months.
State officials did not release the June 2021 findings despite mounting public concerns about Grand Junction-based Mind Springs Health and its psychiatric hospital, West Springs. The problems were so acute that the state’s Medicaid contractor would not authorize payment for newly admitted hospital patients for three months until Mind Springs agreed to make wide-ranging changes.
The investigation found that of a sample of 58 Mind Springs outpatient clients, nearly half received care categorized as having potentially “severe, life-threatening impact.” Two people included in the review died, although public records do not directly attribute their deaths — one from respiratory failure and the other from an overdose of prescription drugs — to the quality of their care.
“If there are things being investigated there and problems being found, the public has a right to know,” said Wendy Wolfe, a Summit County resident whose son has been treated by Mind Springs for more than seven years. “Without public disclosure, how else do we know it’s safe to send our families, our community there?”
State regulatory agencies declined to say why they didn’t alert the public to the prescribing errors. Mind Springs executives did not return calls about the results of the investigation, launched last spring by Rocky Mountain Health Plans.
RMHP is the private company Colorado’s Department of Health Care Policy and Financing contracts to manage and pay Medicaid benefits on the Western Slope. As part of that contract, the company is among those responsible for investigating complaints about Mind Springs and two other Western Slope community mental health centers.
RMHP detailed its concerns in a June letter to the chief medical officer at Mind Springs. They included:
- In the sampling of 58 outpatient clients prescribed high doses of the tranquilizer benzodiazepine between February 2020 and February 2021, there were concerns about the quality of care given to 52. Twenty-eight patients received care so poor they faced “severe, life-threatening impact.” Mind Springs’ medical staff had prescribed many of those patients high doses of stimulants in addition to their benzodiazepine, which places a patient at risk of overdosing. Benzodiazepine use also is particularly risky for people with substance use disorders.
- Nearly half of a sampling of 54 people receiving in-patient care at West Springs had received deficient care. Those patients were readmitted to the psychiatric hospital from February 2020 through February 2021 within 30 to 60 days of having been released.
- Concerns about prescriptions that included prescribing controlled substances with a 30-day supply for high-risk patients and refills given to patients with opioid or other addictions without a visit.
- Failure to document “the specific rationale for prescribing controlled substances” for clients receiving inpatient care.
Mind Springs cut outpatient services after it opened a $34 million psychiatric hospital in December 2018 that doubled its inpatient beds from 32 to 64. It spends nearly three times more on hospitalizations than other community mental health centers and its patients are readmitted at four times the rate, payment data shows.
“If you look at the data, look at readmission rates and follow-up after patient discharge… Mind Springs Health continues to be, at the hospital, off the charts compared to other psychiatric hospitals,” David Mok-Lamme, a Rocky Mountain Health Plans executive, said during a recent town hall meeting in Mesa County. “We’re talking multiple times readmission rates and a fraction of the follow-up rate.”
Rocky Mountain Health Plans conducted its probe last spring after a Mind Springs physician contacted the company about concerns over Medicaid management, prescribing practices, lack of peer review and other treatment problems the whistleblower said were harming patients at Mind Springs facilities.
The Department of Health Care Policy and Financing released the letter detailing Rocky Mountain Health Plans’ findings only after its executive director, Kim Bimestefer, learned that news reporters from the Colorado News Collaborative and the Colorado Springs Gazette were obtaining it another way.
The investigation last spring determined that of the sample of 52 outpatient clients whose treatment was found to have been concerning, one physician was involved in the care of 18, or 35%, of those clients.
Records show that a psychiatrist, Dr. Thomas Newton, resigned from Mind Springs in May after he was placed on administrative leave due to “aberrant prescribing” practices revealed during the investigation. Newton remains licensed to practice medicine in Colorado, and regulators in charge of physician licensing at the Colorado Department of Regulatory Agencies have posted no details about the controversy over his care at Mind Springs on its online license lookup tool. Newton has not returned telephone calls, text messages and emails seeking comment.
An elderly Mind Springs patient who later died was discharged from West Springs hospital with prescriptions for high doses of benzodiazepine and other medications that, when used together, can cause problems with breathing, the investigation found. The man’s death was due to respiratory failure, though the investigation could not definitively link it to improper care. Another patient who received no follow-up care after being discharged from West Springs died due to an overdose of painkillers.
The allegations by the physician who blew the whistle were so serious that in April, Rocky Mountain Health Plans denied Mind Springs payment for new hospital admissions. The halt on payment was lifted after Mind Springs agreed to a corrective action plan in June.
Records show that throughout much of the past year, Mind Springs has remained under that corrective action plan, which requires its facilities to make 17 improvements in protocols to prevent similar life-threatening errors. While many of those changes already have been made, Mind Springs still is finalizing some of the new protocol requirements.
Additional problems have surfaced since the conclusion of the investigation into aberrant prescribing.
In December, Rocky Mountain Health Plans notified state health officials that from July 1, 2018, through Dec. 15, 2021, it had reviewed 472 quality of care concerns involving Mind Springs and West Springs. Of those, 251 — nearly 60% — had some validity, with 68 of those — or 16% — found to have posed severe, life-threatening risks to patients. Some of those cases occurred after Mind Springs agreed to corrective actions last spring.
The Colorado News Collaborative’s reporting in December prompted the three state agencies with oversight over community mental health centers to launch an audit in January into whether Mind Springs is underserving the public.
The health department found “zero deficiencies,” its records show.
The Department of Human Services found only administrative problems. Those range from Mind Springs’ failure to report to the state 40% of critical incidents such as prescription errors or injuries within the required 24 hours, to its pattern of releasing patients from its hospital without the proper paperwork for continued treatment.
Mind Springs’ CEO, Sharon Raggio, and two of its other top executives have resigned since December, when the Colorado News Collaborative exposed the organization’s long pattern of failing to provide safety-net care for which it is paid tens of millions in state and federal tax dollars each year.
This story was reported as part of the Colorado News Collaborative, a coalition of more than 160 news outlets across the state.
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