Red River Behavioral Health System, a psychiatric hospital in Grand Forks, has been cited in state evaluations for failure to individualize treatments for many of its patients. A a result, patients may be receiving less effective treatment that could result in longer hospital stays, according to deficiency reports conducted in 2017 and 2019 by the Centers for Medicare and Medicaid Services in North Dakota.
Red River Behavioral Health was cited with a deficiency when it failed to comply with state and national regulations.
The April 17, 2019, evaluation noted the staff’s insufficient knowledge of regulation requirements as the cause for the lack of documentation and generic treatment plans. It reported similar problems in previous deficiency reports. The hospital received 15 deficiencies in January and seven deficiencies during a followup appraisal in April. Six of the January deficiencies reappeared in the April report.
Red River Behavioral Health System, 1451 44th Ave. S, Unit A, has stated, since the release of the April 2017 report from the Centers for Medicare and Medicaid Services, it would educate employees, audit patients’ treatment plans and update its recording system to fix problems.
“We expect that facilities, as they develop their plan of correction, attempt to look at the root causes that led to the deficient practices,” said Steve Chickering, an associate regional administrator of survey and certification for the Centers for Medicare and Medicaid Services. “It would appear that whatever education, program or components of a program that they utilized did not zero in on the factor that contributed to the deficient practice. The fact that they’ve had this ongoing citation means that they need to look at their root causes a little more closely or a little more in-depth.”
After at least 10 calls and messages from the Herald to Red River Behavioral Health System over the course of a month with no response, a representative of the company said that no one at RRBHS was at liberty to talk about the deficiency reports.
Treatment plans and detailed evaluations represent a starting point toward recovery, according to Chickering.
“You need to individualize it to make sure that the treatment plan is really fully addressing the needs of that particular patient,” said Chickering, adding that a generic treatment plan "could potentially delay a discharge or prevent the patient from fully benefiting from the treatment plan."
As a result of prolonging a patient's hospital stay, higher costs could be incurred. According to RRBHS's fee schedule, consultations with medical professionals, observation, medication and therapy sessions, including group therapy, cost more than $80 each without insurance and can occur multiple times a day. Room and board is $3,000 without insurance. The fee schedule did not make it clear whether this was a per-day charge or for the whole stay, and RRBHS did not respond to a request for clarification.
An example of the facility’s failure to individualize patient treatment plans was in the listing of generic and standard nurse and doctor duties, such as discussing medication and assessing the patient’s mood.
Other treatment plans failed to address patient needs, according to evaluations of the facility by the Centers for Medicare and Medicaid Services, under the auspices of the North Dakota Department of Health and Human Services.
One patient stated that a goal was to “stop thinking about suicide.” The unnamed medical doctor said that a way to achieve this goal was to improve self-esteem and thoughts of self-injury by learning coping skills to deal with those thoughts. However, the medical doctor did not include what events triggered self-harm thoughts in the patient or what coping skills the patient could use.
Another patient wanted to work on behaviors of defiance that the patient felt was preventing a discharge from the facility. Instead, the social worker wrote down a staff expectation — for the patient to discharge to “appropriate living arrangements or a homeless shelter” — instead of the patient’s desired outcome, what specific behavior needed to change or what the plan was for the care of the patient post-discharge.
“There may be a standardized protocol or treatment regimen that the clinicians or practitioners would use as a starting point to institute for a particular patient, but it needs to be individualized based on the assessment,” Chickering said.
Chickering said it was unlikely that the larger number of problems in the January 2019 report as compared to 2017 meant the facility’s standard of care had decreased. Since the deficiencies are surveyed via a sample of patients rather than the whole patient population, it is possible that CMS failed to identify certain deficiencies or problems because they did not appear in the 2017 sample. There might have been some changes within the facility as well, such as staff turnover.
While not all of the individual deficiencies were enough to warrant another inspection or the facility’s loss of its license, the reports show that RRBHS’ noncompliance with certain regulations goes back to the facility’s change in ownership in 2016. It was known as the Richard P. Stadter Psychiatric Center until Meridian Behavioral Health acquired the facility and renamed it.
The deficiencies that appear across all three deficiency reports are as follows:
The facility did not properly include social work roles in treatment and discharge planning.
The long-term and short-term goals listed in the comprehensive plans were generic rather than based on individual patient findings.
The comprehensive treatment plans did not clearly identify staff interventions that addressed specific psychiatric needs.
The medical director failed to adequately ensure that services were appropriate or of the quality needed for individual patients.
The director of nursing failed to ensure that comprehensive treatment plans included nursing interventions that addressed the treatment needs for individual patients.
Though these repeat deficiencies were reported for eight sample patients in the April 2019 deficiency report, they do not require a follow-up survey or put the hospital at risk of losing its license to practice, according to Bridget Weidner, of the North Dakota Department of Health.
In the January 2019 report, the CMS reported two more serious deficiencies. The first was a failure to provide medical records that document assessments and treatments given to patients. The second was having an inadequate number of registered nurses at all times.
Furthermore, the document stated that the facility did not provide appropriate therapy groups and individual sessions and did not employ activity therapy staff, such as music and art therapists, to complete activity therapy assessments recommended in the treatment plan.
The facility did resolve those deficiencies by the time the April follow-up evaluation was completed.
“We think it’s important for … the public to understand the process,” Chickering said of hospital inspections. “It is a spot check. .... It’s based on a sampling methodology … but I think over time it has proven to help entities to identify areas that they need to improve upon. ... So what we’re all wanting is positive outcomes for patients."
Interested parties can search for local hospitals’ deficiency records on HospitalInspections.org. The website, which is operated by the Association of Health Care Journalists, publishes inspection reports to make them easier for the public to access. If recent reports of plans of correction are not available on HospitalInspections.org, people can make a request to CMS or their state’s department of health for the inspection reports.
The Herald was able to receive the reports and plans of correction within five business days of each request and without a formal Freedom of Information Act request.