Legislature(2019 - 2020)CAPITOL 106
03/07/2019 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| Presentation: Alaska Psychiatric Institute | |
| Presentation: Wellpath Recovery Solutions | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 7, 2019
3:02 p.m.
MEMBERS PRESENT
Representative Ivy Spohnholz, Co-Chair
Representative Tiffany Zulkosky, Co-Chair
Representative Matt Claman
Representative Harriet Drummond
Representative Geran Tarr
Representative Sharon Jackson
Representative Lance Pruitt
MEMBERS ABSENT
All members present
OTHER LEGISLATORS PRESENT
Representative Andy Josephson
Representative Dan Ortiz
COMMITTEE CALENDAR
PRESENTATION: ALASKA PSYCHIATRIC INSTITUTE
- HEARD
PRESENTATION: WELLPATH RECOVERY SOLUTIONS
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
ALBERT WALL, Deputy Commissioner
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Presented a PowerPoint titled "Alaska
Psychiatric Institute."
JEREMY BARR, President
WellPath Recovery Solutions
Nashville, Tennessee
POSITION STATEMENT: Presented a PowerPoint titled "Wellpath
Recovery Solutions."
DR. KEVIN ANN HUCKSHORN, Senior Consultant
Wellpath Recovery Solutions
Nashville, Tennessee
POSITION STATEMENT: Presented a PowerPoint titled "Wellpath
Recovery Solutions."
ACTION NARRATIVE
3:02:37 PM
CO-CHAIR TIFFANY ZULKOSKY called the House Health and Social
Services Standing Committee meeting to order at 3:02 p.m.
Representatives Zulkosky, Spohnholz, Pruitt, Tarr, Claman,
Drummond, and Jackson were present at the call to order. Also,
in attendance were Representatives Josephson and Ortiz.
^PRESENTATION: ALASKA PSYCHIATRIC INSTITUTE
PRESENTATION: ALASKA PSYCHIATRIC INSTITUTE
3:03:20 PM
CO-CHAIR ZULKOSKY announced that the first order of business
would be a presentation on the Alaska Psychiatric Institute.
3:04:43 PM
The committee took a brief at-ease.
3:05:38 PM
ALBERT WALL, Deputy Commissioner, Office of the Commissioner,
Department of Health and Social Services, presented a Power
Point titled "Alaska Psychiatric Institute." He reported that
upon appointment to Department of Health and Social Services
both he and Commissioner Crum were aware that there were
extenuating circumstances at the Alaska Psychiatric Institute
(API), which he described as "difficult." He added that "there
was a lack of open beds, lack of staffing, and there were safety
and security issues including the issue of restraint and
seclusion." He opined that, at the outset, neither he nor
Commissioner Crum were aware for the severity of the problems.
He pointed specifically to the "timeline of certification and
survey process for plans of correction." He reported finding
several critical issues at API, and he shared slide 2, titled
"Critical Issues at the Alaska Psychiatric Institute." These
issues included staff and patient safety, inability to fulfill
its mission, pending legal issues with extreme risk of high cost
to the state, and the ethical treatment of Alaskans.
3:07:28 PM
MR. WALL introduced slide 3, titled "Regulatory Relationships,"
which depicted an overview of the regulatory authorities at API.
He pointed to Professional Licensing, noting that the
requirements changed for each type of profession and each had
its own licensing requirements which delineated what could and
could not be done for health care. He noted that each of the
remaining regulatory bodies were outside the organization,
looking in at conditions in the hospital.
3:08:17 PM
MR. WALL introduced slide 4, "Occupational Safety and Health
Administration," reporting that this was a Federal agency that
sets and enforces protective workplace safety and health
standards, and that it may levy fines on agencies not in
compliance. He referenced a report that the department had
received from OSHA (Occupational Safety and Health
Administration) which declared that API was an unsafe workplace.
3:08:49 PM
MR. WALL moved on to slide 5, "Alaska Ombudsman," and explained
that among the many services provided, this agency investigates
complaints that involve state agencies and determines
appropriate remedies. The Alaska Ombudsman had initiated an
investigation in July of 2018 and the final report of findings
was given to the Department of Health and Social Services
yesterday [March 6, 2019] evening.
3:09:33 PM
MR. WALL addressed slide 6, "The Joint Commission," and
explained that this was a national, not-for-profit accrediting
organization for nearly 21,000 health care organizations. It
provides peer-to-peer standards for members, offers joint
evaluations, and holds and certifies each member to professional
standards. He added that the commission could also be an agent
for the Centers for Medicaid and Medicare Services and may act
in their stead to inform on deficiencies in organizations. He
added that API was currently under a plan of correction with the
Centers for Medicaid and Medicare Services.
3:10:30 PM
MR. WALL presented slide 7, "Health Facilities Licensing and
Certification," which read: "To operate in Alaska, a hospital
must be licensed by the state under AS 47.32. The Department
sets standards and requirements for licensure (through state
regulations). If API does not maintain state licensure, it
cannot operate."
CO-CHAIR SPOHNHOLZ asked if any hospital in Alaska had lost its
license.
MR. WALL replied that he would find out and "I can get it to
you."
3:11:23 PM
MR. WALL directed attention to slide 8, "Centers for Medicare
and Medicaid Services." He added that, as Medicaid evolved out
of the Medicare law, Medicare itself was the "key to all federal
funding, it's all tied up in the same statute federally." He
stated that CMS (Centers for Medicare and Medicaid Services)
provided oversight for health care services and controlled all
federal funding to all facilities and providers throughout the
nation. He reported that API received approximately $23 million
annually in federal funding, dependent on how much Medicaid was
billed each year. API must meet federal requirements to receive
funding and meet Conditions of Participation (CoPs)
(certification of compliance with the health and safety
requirements). If these conditions are not met, the
certification would be withdrawn and there would not be the use
of any federal funds. He pointed out that there were several
surveys at every facility through CMS, and that some of these
were triggered by complaints filed for issues at the facility,
or by a report of harm or a report of an incident which was
required to be reported to a CMS authority. He noted that some
of these surveys were on a routine basis to ensure compliance
with the rules and regulations.
3:12:58 PM
MR. WALL moved on to slide 9, "Conditions of Participation for
federal funding." He stated that API must be in "substantial"
compliance with each Condition of Participation, which was a
little bit different for each type of facility. If a hospital
is not in substantial compliance and does not correct by the
deadline, CMS will de-certify the hospital and terminate its
participation in Medicare and Medicaid.
3:13:42 PM
MR. WALL presented slide 10, "Types of Citations," and explained
the three types of citations that could be issued in a survey,
although each of these three consisted of hundreds of individual
types of deficiencies: standard level deficiency, which was out
of compliance with a specific regulation that could usually be
easily fixed; condition level deficiency, which was very
serious, as the facility would be found to be not in compliance
with its CoP, although this was fixable through a plan of
correction in an ongoing fashion; and finally, immediate
jeopardy, which was deviation from regulatory standards and was
an immediate threat to patient health and safety, including life
or limb, or a humanitarian issue. He labeled immediate jeopardy
as a "showstopper" which could lead to an immediate shutdown of
a facility if it was not immediately dealt with in a manner
satisfactory to the survey team.
3:14:53 PM
MR. WALL directed attention to slide 11, "Immediate Jeopardy,"
which was defined by the CMS State Operations Manual as "[a]
situation in which the provider's noncompliance with one or more
requirements of participation has caused, or is likely to cause,
serious injury, harm, impairment or death to a resident."
3:15:14 PM
MR. WALL shared slide 12, "Plans of Correction," and stated that
these plans start as a negotiation with CMS after their survey
and findings are presented to the hospital. Although the
Hospital has 10 calendar days to provide an acceptable Plan of
Correction for each cited deficiency, the plan may not be
accepted initially by CMS. If the hospital doesn't come into
compliance by the deadline, the state agency certifies
"noncompliance." He explained that the first plan of correction
had 90 days, with a subsequent re-survey to determine
substantial compliance. If still not in compliance, this was
extended an additional 90 days. The hospital would be out of
time after 180 days, and there were not any more extensions.
CO-CHAIR SPOHNHOLZ asked about the date for the event which
initiated the Plan of Correction for API.
MR. WALL, in response, explained that every time there was a
survey team which found a deficiency, a plan of correction was
written. He stated that, currently, API was under many plans of
correction, with the latest being on January 29. He pointed out
that API was still working on plans of correction from previous
visits. He added that plans of correction could have multiple
dates, as they were working from multiple survey dates.
CO-CHAIR SPOHNHOLZ asked if it was "fairly common that there is
an issue that's been identified that a plan of correction is
requested and then you provide the plan of correction and then
there's routine follow-up just to make sure that you're actually
implementing."
MR. WALL replied that was correct.
CO-CHAIR SPOHNHOLZ asked if this was typical and happened with
fair frequency.
MR. WALL replied that it depended on the level of deficiency.
He reported that API had a survey team from a regulatory body
engaged in a high level of scrutiny and involvement in the
building almost every other week for the previous 8 - 9 months.
MR. WALL moved on to slide 13, "API Plans of Correction." He
reported that the 180-day timeline mark for API compliance on a
Plan of Correction had been passed on November 26. He pointed
out that there was not a plan of correction that had been
accepted by the federal government for the July survey, noting
that the July survey had been on the day of the earthquake,
resulting in a state of emergency. Consequently, API had been
granted another extension which expired on February 1.
3:19:13 PM
CO-CHAIR SPOHNHOLZ asked if Mr. Wall was discussing the CMS
citations dated July 19, and the Plan of Correction in response
to this citation.
MR. WALL suggested that this was correct. He added that a Plan
of Correction was a dialogue between the agency and the
government, and he offered his understanding that, as of that
date, there was not a plan to which both sides agreed. He
clarified that this did not mean that work was not being done to
come into compliance with the issues or to mitigate the
deficiencies. It only meant that the documentation had not been
accepted.
CO-CHAIR SPOHNHOLZ reported that she had reviewed a series of
survey citation reports in which the former director, Duane
Mays, had responded to CMS. She noted that these documents had
been dated and signed on September 17, 2018, most of which were
due to be completed in November. She asked if Mr. Wall was
indicating that there had not been any progress on any of these.
MR. WALL replied that, although work was being done, the
finalized version of the plan of correction had not been agreed
upon by both sides.
REPRESENTATIVE SPOHNHOLZ asked to ensure that work was in
progress, and it was not as if the issues had been identified
but no work had been done.
MR. WALL expressed his agreement that work had been done. He
relayed that it was necessary to have an accepted plan of
correction and then show substantial compliance with that plan
by the time the survey team returned. He offered an example
from the previous administration in which the plan of correction
had taken a long while to put together and, as the date for
return of the survey team "was looming," there was less of a
chance for showing substantial compliance. He offered an
example for the difficulty of scheduling new staff training
while still maintaining full staffing during work shifts.
3:22:01 PM
MR. WALL moved on to slide 14, "Seclusion & Restraint," adding
that this was a specific problem resulting in numerous citations
for API and had been the bulk of the findings in the survey
prior to January 29. He stated that seclusion and restraint was
a difficult and tenuous issue in psychiatric care. He explained
that some patients, admitted civilly under Title 47, were a
danger to themselves or others. This could result in seclusion
and restraint through a court issuance which could only last for
a short period of time and only for emergent self-protection.
He added that other patients, admitted criminally under Title
12, had been evaluated for restorative care for purposes of
competency to stand trial for the crime to which they had been
charged. He noted that these patients could be dangerous.
Seclusion and restraint were a reality for in-patient
psychiatric care, although it was "a difficult line to walk."
He reported that API had a much higher rate of seclusion and
restraint than was accepted in the field, noting that many
examples had been posted for instances when it possibly should
not have been occurred, especially for the length of time.
3:23:48 PM
CO-CHAIR SPOHNHOLZ asked about the high seclusion and restraint
rates and how they compared to the national standard.
MR. WALL replied that these charts were posted on the website
with a monthly standardized report showing the API rates
compared to the national average.
CO-CHAIR SPOHNHOLZ mused that API did appear "a little bit high"
and in "other areas we're kind of in the middle." She asked
what was the concrete benchmark, and where was API in actuality.
She pointed out occasional spikes in the chart, noting that one
challenging patient could be the cause. She asked to better
understand what the normal standard was and why it would be
occasionally higher. She asked what the committee should be
aware of regarding performance metrics.
MR. WALL replied that this was "both a blend of the rate of
incidence and the actual incidents itself and whether or not it
was appropriate to restrain them." He said that the big problem
resulting from the surveys was the individual instances of
seclusion deemed to be inappropriate and outside the standard.
He allowed that there could be an indication for how well the
institution was doing with issues of violence, aggression, and
de-escalation by comparison to the rate on the charts. He
pointed out that the individualized case studies with video
feedback indicated what had occurred and whether the response
was appropriate.
3:26:43 PM
CO-CHAIR SPOHNHOLZ pointed out that, as safety and seclusion and
restraint problems were some of the rationales for initiating a
very controversial approach to changing the operations at API,
it would be helpful for the committee to be presented with more
concrete specifics for absolute appropriates and how API had
deviated from this norm.
MR. WALL replied that the reports and survey findings on the
website shared very specific actions for what happened and what
should have happened. Each finding cited where the action had
gone outside the regulatory standard for that instance. He
explained that it was difficult, as each instance was weighed,
and each may have failed in a different regard to the standard.
REPRESENTATIVE SPOHNHOLZ asked for a link to that report.
3:27:58 PM
REPRESENTATIVE JACKSON directed attention to slide 14, which
noted the right to be free from physical or mental abuse and
corporal punishment, as well as to be free from restraint or
seclusion, and asked about the employee options when dealing
with a patient acting out. She questioned whether the employee
could be put in danger without having these options.
MR. WALL expressed his agreement with this dilemma. He shared
that it was very difficult to work with patients at this acuity
level, as they could be dangerous. He said that the primary
training was based on de-escalation, adding that the training
used at API was the Mandt System. He read from slide 15, titled
"Seclusion & Restraint at API": "Since 2011, there have been
seven separate independent reports indicating API uses seclusion
and restraint inappropriately and/or excessively." He pointed
out that this combination caused the problem in specific
incidences. He shared an example of an individual who was ill,
with symptoms of occasional violence. He pointed out that a
vindictive response, using restraint as a punishment, was not
the correct way to deal with the patient. He read further from
slide 15: "Since 2017, API has been cited at least seven
separate times for deficiencies including violations of patient
rights and use of seclusion and restraint." He added that the
largest areas of deficiency were with seclusion and restraint.
3:31:07 PM
REPRESENTATIVE CLAMAN asked where to draw the line, noting that
many of the complaints were in the gray area, as the incident
justified some use of restraint, and although it may have been
for too long, it did not appear to go too far.
MR. WALL replied "I don't believe in gray areas in the
regulations for that particular issue. It's a matter of patient
care and human rights." He emphasized that having someone in
restraints for 30 minutes longer than necessary was wrong. He
shared an example of a patient who was verbally loud and
assaultive, and the staff were attempting to de-escalate. The
patient was asked to walk on his own to the seclusion and
restraint room. He posed whether this was clinically necessary
as the patient was not violent or a danger to himself or others.
He said that this was not within the standards of care if the
patient was only yelling; hence, this was a violation of the
individual's rights. "It's a clear line."
3:33:39 PM
REPRESENTATIVE CLAMAN said that, although it may appear to be a
clear line, there may have been prior behavior that required a
"five-minute time out, a fairly routine technique that's used
not just in psychiatric hospitals, but parents use it all the
time with children." He offered his belief that this was a grey
area that could be argued on both sides and that it depended on
the details of the circumstance. He asked if the incidences
mentioned in the reports could be argued on either side.
MR. WALL acknowledged that there were times when a patient would
voluntarily take a time out to calm down. He explained that a
grey area was reviewed by a CMS professional looking at the
situation for determination whether an incident broke a
regulation, law, or procedure. He stated:
that's what we're looking at. I can look at things
from the outside a certain way and come up with one
conclusion, but, when the expert on the ground is
telling you this is wrong, and here's why, and it's in
the report, that's your final answer.
MR. WALL declared that in-patient psychiatric care was a legal
issue. He reported that the ability for the state, or a doctor,
to medicate an individual against their will or put them in
restraint or seclusion against their will was a difficult line
for attorneys, judges, and care providers to walk. He offered
his belief that the experts on the ground had the authority to
make the determination.
3:37:15 PM
REPRESENTATIVE CLAMAN asked whether a CMS review after an
incident would determine inappropriate behavior even though the
finding at the time had determined the staff action to be
appropriate.
MR. WALL, in response, said that, although he could not speak to
a specific incident, in his personal experience this had
occurred. He pointed out that, although there were gradations
of an individual's perception to an action, in psychiatric care
the authority rested on the surveyor's determination of legal
compliance, clinical appropriateness, or the right thing to do
for the patient.
3:38:32 PM
REPRESENTATIVE JACKSON asked about mental abuse toward the care
giver by a patient. She opined that there must be a very high
turnover of staff. She mused that it must be a very thin line
between protecting the patient or protecting the care giver.
MR. WALL expressed his agreement that it was "a very difficult
road to walk." He reported that, although there was a wide
range of symptomology for individuals with a serious mental
illness, caregivers had to change their perception to better
understand this was a symptom of the illness. He shared his
experience as a psychiatric nurse. He pointed out that many of
the patients at API had been deemed non-competent and were not
held accountable for their actions.
CO-CHAIR SPOHNHOLZ expressed her concern that API employees had
called the Anchorage Police Department (APD) on patients, as, by
definition, admittance into API determined a lack of competence
and accountability by a patient. She asked if API employees
were no longer contacting APD when, in other circumstances,
these actions by patients would be considered assault or
illegal.
MR. WALL replied that this was another difficult line to walk.
He declared that, as all staff had a right to personal safety,
sometimes the police were called. He explained that this
becomes an issue when an individual taken into custody had to be
charged with a crime, but they were sent back to API for care,
as it was the only place to send them. He acknowledged that
there had been assaults on staff, and he allowed that staff had
the right to call the police and file charges even as the system
was designed to return the person to API for care.
CO-CHAIR SPOHNHOLZ opined that it was counter intuitive to hold
a person accountable after their civil liberties had been
removed because it had been determined they were not competent
to be free and accountable. She expressed that the problem was
an underlying issue for not having enough staff and enough well-
trained staff more than an issue of culpability for people with
mental illness who had been put in the only acute psychiatric
in-patient hospital in Alaska.
MR. WALL expressed his agreement. He stated that most of the
API staff were there for the right reasons, to care for
individuals with the symptomology, and they worked at API by
choice as they enjoyed working with this population. He
reiterated that staff at API had to maintain awareness for the
potential for violence by the patients. He referenced slide 15,
"Seclusion & Restraint at API," and directed attention to the
just completed Ombudsman investigation, which read:
API does not take reasonable and necessary action to
prevent and/or mitigate the risk of harm to patients
from use of force by API staff; API does not take
reasonable and necessary action to prevent and/or
mitigate the risk of harm to patients due to violence
by other patients; API does not consistently comply
with AS 47.30.825(d) or 42 CFR 482.13(e) in the use of
seclusion and restraint.
MR. WALL added that he was looking forward to working with the
Ombudsman for the findings on the report.
3:46:03 PM
MR. WALL moved on to slide 16, "Safety at API." He pointed out
the multiple citations issued by Alaska Occupational Safety and
Health (AKOSH) to API: in December 2014, API failed to provide
its employees with a safe work environment and API failed to
maintain its OSHA log from 2011 to 2013, including not
accurately reporting injuries or related incidents; in November
2017, there were 24 reportable incidents during 6 month
timeframe and API failed to maintain its OSHA log and accurately
report injuries from 2014-2017. He pointed out that these
citations were very similar. He noted that the 2015 report
found that API was seriously and "dangerously" understaffed,
compensation was too low, and hiring takes too long. (Dvoskin
report.) The September 2018 report by attorney Bill Evans found
that the hospital was an unsafe work environment for staff
(including a cultural divide on the use of seclusion and
restraints). In September of 2018, the injury rates at API
doubled and on January 29, 2019, surveyors found an unreported
"immediate jeopardy" incident.
3:47:36 PM
CO-CHAIR SPOHNHOLZ stated that the issue for staffing at API had
been recognized for a very long time, noting that this was
underscored by the Dvoskin report. She pointed out that the FY
20 proposal included a request for an additional 80+ staff for a
total of 359 staff in order to be staffed at a safe level for
both patients and staff; whereas, the proposal submitted by
WellPath to the State of Alaska for management of API was for
only 276 staff. She expressed her concern for this low number
of staff as currently API only had a "few dozen fewer staff than
that on site." She opined that without a major infusion of both
training to improve expertise and staff capacity, it would not
be possible for API to reach a safe and therapeutic environment
and return to a place of healing and recovery.
MR. WALL replied that, as there were different methodologies and
curriculum trainings by individual agencies to address certain
problems, the staffing ratios changed accordingly. He offered
an example for staffing based on different protocols. He
explained that there was a therapeutic approach and well thought
out plan by medical professionals for problem solving, and each
clinic could be a little different. He reported that API had
not had a comprehensive clinical approach in a very long time,
as there had been so much changeover in the leadership
positions. He stated that the issue was not just for numbers of
staff, but was about a comprehensive, coherent, and appropriate
clinical approach to a problem for which everyone was trained
and in agreement.
3:51:59 PM
CO-CHAIR SPOHNHOLZ expressed her agreement with the need of
consistency in leadership in order to develop and execute a
plan. She noted that one problem in leadership was a failure to
execute on good plans and good work. She offered her belief
that the leadership at API under former Director Duane Mayes had
done a lot of work to "put in place plans which were designed to
improve safety." She emphasized that patient to staff ratio was
an important factor, especially when dealing with very ill
patients. She shared that 276 staff to 80 patients was a 4.5
[staff] to [patients] ratio in a 24/7 facility. She pointed out
that, as some of these staff cleaned, cooked, and handled
communications and security, not all these staff were working in
direct care for patients. She reported that with 359 staff at
API, as proposed by former Director Mayes, the ratio would drop
to a 3.5 staff to patient ratio. She pointed out that some
patients required one on one or two on one care in a very
specific, "crisis melt down situation," adding that having more
personnel was a good thing in a facility such as API. She
emphasized that the current administration had initiated another
leadership change at API, while simultaneously arguing that
leadership consistency was important. She opined that, instead,
it may have made sense to stick with the Duane Mayes
administration and make the investment of $44 million included
in the previous FY 20 Walker budget. She declared that this
would have allowed consistency of delivery with the opportunity
to execute a plan, resulting in much lower conflict, crisis, and
controversy caused by the introduction of a non-Alaska partner
to run API.
3:55:05 PM
MR. WALL presented slide 17, "Staffing at API," a November 2011
WICHE (Western Interstate Commission on Higher Education) report
and read:
The pressures created by the combination of resource
limitations, staffing shortages, recruitment
challenges, admission and census increases, and
limited access to decision support tools all combine
to increase risk for the facility and the patients and
staff of API. This set of challenges has reached
crisis proportions and it is not realistic to approach
these issues with modest adjustments to existing
processes.
MR. WALL offered his opinion that these issues from 2011 had not
changed to date and the problems had not been solved. He
reported that he and the current commissioner came into office
in December [2018] and discovered issues at API "at a point
when, literally, the ball was rolling down the hill too fast and
we had to stop it," they began to speak with potential partners
about a wide variety of ways to work together to solve these
issues, which included consultants to work on individual issues
for a plan of care, consulting by an administrative services
organization to write a plan of correction, partial
privatization, and full privatization. He stated that these
talks to get a plan of correction into place and remain
certified with CMS were still ongoing up to January 29, 2019,
when the survey team returned and found the immediate jeopardy.
At that point, they decided that something had to be done
immediately or "the doors at API are going to be closed." He
shared his understanding for the public concern that the problem
was not that dire, but "I can assure you it was. The doors at
API could have closed, and frankly, still can." He pointed out
that non-compliance for the plans of correction would result in
the loss of certification, accreditation, and license.
3:58:29 PM
CO-CHAIR SPOHNHOLZ asked if, during the exploration of options
for operating solutions, was there any exploration for staying
the course.
MR. WALL replied, "yes" and he reiterated that they had been in
the process of writing the plan of correction with the remaining
API staff.
CO-CHAIR SPOHNHOLZ shared that many people were very interested,
had paid close attention to API, and were very aware of the
safety issues. She reported that since a presentation about the
safety issues at API in April [2018] she had worked with
partners to secure an additional 20 PCNs [primary care nurses]
and other personnel on-site, and to offer hiring bonuses and
raises to re-classify positions for appropriate recruitment and
retention of staff, in order to be competitive with the market.
She shared that there were concerns after the Evans Report
detailed that the previous leadership had not been accountable
and transparent enough with the problems at API and the need for
resolution. She reported that Duane Mayes, a respected and
credible manager, had been hired and had been working on a "very
credible plan for turning around API, which includes staffing at
the right levels, it includes letting go of some staff that have
proven to be less than meaningful contributors to the
advancement of the mission of API." She emphasized that she did
not understand the reason for a change in leadership and a "pull
back" on the budget, the investment, and the strategies already
being implemented as they were based on proven models of
leadership for getting to the correct safety level at API. She
asked why there had been a change.
MR. WALL replied that it was Mr. Mayes' personal decision to
move to his current position, adding that he was "good at both
roles."
CO-CHAIR SPOHNHOLZ offered her belief that the desire "from the
very beginning of this administration to privatize API" took
precedent over any other strategy to invest in API. She pointed
out that the budget proposal by the current administration was
$33 million, less than what was needed to operate the proposed
contract and less than what was needed to ensure that API was
safe. She expressed her concern that this would result in
another debacle and asked how this proposal was any different.
MR. WALL deferred to an upcoming budget proposal to be presented
to the House Health and Social Services Standing Committee. He
allowed that the "emergent nature of what occurred [on] January
29th is what drove a decision for change."
CO-CHAIR SPOHNHOLZ interjected that the budget issues were
"pretty damn important." She pointed to the proposed contract
with Wellpath [Recovery Solutions] which stipulated that it was
subject to appropriation. If the State of Alaska does not
appropriate the full amount necessary to operate API meeting the
contract, and the contract obligated the State of Alaska to $44
million in FY 20, then Wellpath could step back from operation
of API at any point in time. She offered her belief that this
could possibly set up the state for another potential crisis, if
there was not "a rational strategy to execute."
MR. WALL replied that this "can be answered from both sides of
the house" during the upcoming budget proposal presentation and
the Wellpath Recovery Solutions presentation.
4:02:57 PM
CO-CHAIR ZULKOSKY stated that, although there was a lot of
passion behind the issue, it was important to continue with
respect from both sides of the table.
4:03:10 PM
REPRESENTATIVE JACKSON asked to finish the presentation.
4:03:30 PM
MR. WALL returned to slide 18, "Recruitment." He said that
there had been efforts to increase recruitment as there were
several vacant positions. He reported that, as it had been
since July 2017 that API had been at its full 80 bed capacity,
this was used as the starting point for reviewing the net gain
in recruitment. He reported that, since 2017, there had been a
loss of 2 nurses, even as 12 nurses had been hired in 2017, 12
more nurses had been hired in 2018, and 2 nurses had been hired
in 2019. He pointed out that this indicated a turnover rate.
He stated that recruitment for social workers and mental health
clinicians was much the same, reporting that the hires and job
losses had resulted in a net gain of zero since 2017. He added
that there had been a loss of 6 staff medical providers since
2017, which included psychiatrists, as well as advanced nurse
practitioners and physician assistants with psychiatric
specialty.
4:05:40 PM
MR. WALL moved on to slide 19, "Vacancies," reporting that there
was continue recruitment for state positions.
4:06:02 PM
CO-CHAIR SPOHNHOLZ asked how many positions at API had been
filled since he began his position in December [2018].
MR. WALL replied that two nurses had been hired and that the
lack of qualified applicants made recruitment lengthy and
difficult.
4:07:26 PM
REPRESENTATIVE CLAMAN asked if any psychiatrists had been hired
since the two psychiatrists at API were fired for failure to
sign the governor's loyalty oath.
MR. WALL offered his understanding that no one had been hired.
REPRESENTATIVE CLAMAN asked if there was a lawsuit pending
regarding that firing.
MR. WALL replied that, although he was aware a lawsuit had been
filed, he did not know the current status. He shared that he
understood the perspective of the two psychiatrists, and,
although from one perspective it appeared to be a firing, both
he and the commissioner had met with the two psychiatrists, had
asked them to stay, and it had been the choice of the two
psychiatrists to leave.
REPRESENTATIVE CLAMAN noted that it was the insistence by the
administration on a loyalty oath, offering his belief that this
was "completely inappropriate."
4:08:45 PM
CO-CHAIR ZULKOSKY reminded everyone that all comments and follow
ups were to be requested through the chair.
4:08:59 PM
MR. WALL referenced the pending legal issues with financial
ramifications "hanging over the State's head at this time." He
directed attention to slide 20, "Forensic Psychiatric Services
AS 12.47.010." He reported that when a forensic patient has
been charged with a crime, and if they are suspected to be
incompetent to stand trial, they are sent to API for 90-day
restoration increments before re-evaluation. He reported that
the evaluation process and restorative care did not happen in a
timely fashion. He declared that, although API had an
obligation to evaluate individuals in Department of Corrections
facilities and get them into restorative care if this was the
appropriate course of action, this was not happening. He moved
to slide 21, "Forensic Unit (Taku)" and shared that daily there
were about 80 individuals waiting for the evaluation process or
waiting for a bed for restorative care to become available. He
shared that the average length of stay for individuals
inappropriately placed in the Department of Corrections waiting
for an evaluation or restorative care could be up to 136 days,
although these individuals had not been convicted of a crime.
He declared that this created a liability for the state, noting
that there could be a Department of Justice injunction and the
state could be fined until the problem was rectified. He stated
that, although this was a financial issue, it was also an
ethical dilemma as it was "wrong for us to leave individuals in
prison for that long of a period of time without treatment and
without conviction of crime." He reported that this was one of
the issues at API as there was only a 10-bed ward for 35
forensic patients and the department was moving rapidly to
address this issue. He suggested that the State could find an
evaluator to go into the prisons for the evaluation process,
noting that there was the same wait for felony and misdemeanor
charges. He pointed out that faster evaluations could reduce
the number of people in prison. He added that help from
partners could allow ad-hoc forensic teams to bring more beds
on-line. He explained the staffing ratio for forensic units for
restorative care.
4:14:53 PM
CO-CHAIR ZULKOSKY asked about the possible partners.
MR. WALL said that he went to the ASHNA [Alaska State Hospital
and Nursing Home Association] meeting and "made that plea to
everybody." He added that more evaluation and treatment beds
had been designated statewide, and he offered examples from
around the state.
4:16:05 PM
MR. WALL turned to slide 22 "Legal Involvement," and said that,
although he could not speak directly to an active lawsuit, the
jeopardy for liability was real and ongoing and seemed to mirror
the progress in other states.
REPRESENTATIVE CLAMAN asked for the meaning of "DLC."
MR. WALL explained that this was the Disability Law Center.
4:16:56 PM
MR. WALL moved on to slide 23, "Civil Commitments AS 47.30.700."
He shared that a problem in many states, including Alaska, was
for a lack of psychiatric beds. In a civil situation in both
hospitals and correctional institutions, if a person was found
to need a bed for in-patient care, yet there were not any beds
available and the patient was required to stay in their current
setting without the necessary care, then the state could be
found liable. He pointed out that the hospitals were bearing
the brunt of the workload and the cost, which was difficult to
bear.
MR. WALL shared that there were several case studies, including
slide 25, "Washington," slide 26, "Pennsylvania," slide 27,
"Utah," and slide 28, "Louisiana." He directed attention to the
case study in Washington, an on-going case of liability. He
reported that there had been a lawsuit with a subsequent trial
in 2015 for constitutional rights, like the issue in Alaska. He
noted that, in July 2016, there was a contempt order that
stated, after 7 days, the state pay $500 per day per person, and
after 14 days the fine was to be increased to $1,000 per day per
person. He reported that currently in the Department of
Corrections there were about 80 people included in this
category, which carried a significant financial liability. As
of June 2018, the fines in the State of Washington exceeded $55
million, which did not include the on-going treatment. He
reported that the settlement had also required a change by the
state in five substantive areas, some of which required the
building of new service facilities.
4:19:57 PM
MR. WALL directed attention to slide 29, "The decision to
contract." He shared the goals for seeking a contractor: to
ensure the safety of our staff and patients; to bring the
hospital into rapid compliance with regulatory authorities; and
to prepare the facility to increase its bed capacity to 80 beds
by 1 July. He relayed that following the immediate jeopardy
finding in the survey, there was discussion with Wellpath for a
plan of correction, which had taken more than 180 days to be
accepted by both sides. He reported that the plan of correction
on the findings in January had already been accepted, which he
called "a good step in the right direction." He stated that it
was unprecedented for the organization not to be de-certified
because of the immediate jeopardy. He added that CMS was
working with the state.
4:21:04 PM
CO-CHAIR SPOHNHOLZ asked about the process for the selection of
Wellpath, noting that she had read the supporting documents
regarding the three companies contacted. She asked if a non-
profit organization or a local organization had been willing to
partner in either a turn around contract or an operational
contract at API.
MR. WALL replied that they had not found either, that part of
the issue was the necessary speed for a company "to get experts
on the ground to assist us in particular in the area of safety."
CO-CHAIR SPOHNHOLZ stated that she was "a little confused by
that." She reported that she had had conversations with
Providence Health Systems, which had expressed interest and had
offered, to operate API. She noted that Providence Health
Systems had asked for an invitation to submit a proposal, should
an RFP (Request for Proposal) be offered and had reached out to
help in any way. She pointed out that Providence Health Systems
already had a demonstrated track record in the State of Alaska
and was already doing acute, in-patient psychiatric care right
across the street from API. She offered her belief that they
were a natural partner and would be received more warmly by the
community.
MR. WALL shared that he had also spoken with the CEO at
Providence Health Systems, and acknowledged that they had
expressed interest in the past. He noted that the detail for
what they could take on and the speed with which they could move
were also parts of the conversation. He expressed his
willingness to speak with Providence Health Systems regarding a
role.
CO-CHAIR SPOHNHOLZ said that she could not find any
documentation of any conversation with Providence Health Systems
in December. She asked if there was a conversation with them in
December specifically, and whether an outreach phone call to
Providence Health Systems had been made when the decision to
bring in outside expertise and capacity to help operate API was
made.
MR. WALL replied that he was unsure of the specific date for his
contact with Providence Health Systems.
CO-CHAIR SPOHNHOLZ asked that Mr. Wall report back with the
date. She said, "it strikes me as unusual to see a series of
outreach to organizations, none of which are operating in the
State of Alaska or have, some of which don't really have a track
record of doing this specific kind of work." She pointed out
that, as Providence Health Systems was already offering in-
patient psychiatric care "right across the street, they seem
like a much more natural partner and one which, I think, the
community would be much more receptive to."
MR. WALL said that he would provide the date, adding that he had
a phone conversation with [Providence Health Systems], although
he was not sure of the date.
CO-CHAIR SPOHNHOLZ asked if there was a concern for the ability
of Providence Health Systems to fully staff API "in a quick
enough manner." She asked why exploration for this partnership
had not been pursued.
MR. WALL offered his belief that the conversation with
Providence revolved around the issues of civil and forensics
commitment.
CO-CHAIR SPOHNHOLZ asked whether there was any way to have a
hybrid model and include a working partnership with Providence
Health Systems.
MR. WALL opined that, although there was the possibility of a
partnership at some level, the response for the emergency on
January 29 had driven the decision for a partner "on the ground
and emergent control as quickly as possible." He reported that
Wellpath offered a team of specialists that would quickly cover
the entire spectrum of the requirements from the plan of
correction and would address this with CMS. He pointed out
that, although many of the API leadership positions were
currently vacant, the Wellpath team of specialists mirrored
these leadership positions. He added that there had especially
been a focus made toward the fulfillment for the rapid response
team.
CO-CHAIR SPOHNHOLZ countered that part of the reasons for the
vacancies in the leadership positions at API were because of
decisions made by the current administration. She pointed out
that Providence Health Systems was part of a large, seven-system
network, with mental and behavioral health professionals working
across the region. She suggested that there could have been
exploration for a variety of operational models which she would
have "received much more warmly."
MR. WALL, in response, said that he spoke to the executive
director of the Providence mental health foundation and that
there would be another conversation for a discussion for
partnership.
4:27:20 PM
MR. WALL presented slide 30, "Immediate Jeopardy Finding." He
reported that the jeopardy situation on January 29 had been a
patient on patient assault and that the perpetrator had been
placed on their own vacant ward. He paraphrased from the slide,
which read:
Implemented new safety protocol including 24/7 video
surveillance with communication to the wards;
Implemented an hourly reporting system for each ward
to monitor every patient on an hourly basis including
behavioral risk mitigation; and requested a nationally
recognized specialist in psychiatric treatment and
safety, and NASHMPD to come to API immediately for
safety oversight.
4:28:38 PM
CO-CHAIR ZULKOSKY asked whether, when a finding was found and
immediate steps were taken for resolution, this finding would be
absolved and not impact accreditation.
MR. WALL replied that "in some cases it can, and in some cases
it doesn't." He clarified that the discussion was not about
accreditation, compliance with a set of standards; but it was
for certification. He explained that there had been a legal
discussion with CMS to determine whether API was "in compliance
with your conditions of participation legally to have the
contract with the federal government to receive federal funds."
He stated that this was a different relationship. He offered
his belief that this was the first immediate jeopardy at API and
that, sometimes, when a serious deficiency was found and
immediately responded to, it would fix the problem. He noted
that, in this case, the question was now for resolution to
prevent recurrence. He stated that the lingering effects were
for procedure and how situations would be handled in the future
as opposed to the immediate placement of a patient in another
ward.
4:30:16 PM
CO-CHAIR SPOHNHOLZ referenced the immediate actions after the
incident to ensure safety and opined that the documentation of
the incident had not "made it all the way through to formal
reporting." She asked if this issue with documentation had been
identified by CMS as problematic.
MR. WALL, in response, said that the most egregious problem was
that the perpetrator was not removed from the victim, nor was
the victim assisted with any follow-up. He declared that it was
not a matter of paperwork transfer. He explained that "the lack
of paperwork transfer produced a lack of care in intervention."
CO-CHAIR SPOHNHOLZ noted that, in her review of the supporting
documents for the procurement, she had found a curiosity in the
timeline of the immediate jeopardy episode. She referenced an
e-mail dated January 22 in which Mr. Wall described an upcoming
CMS survey team site visit for the following week on either
January 28 or January 30. She noted that the seventh bullet of
this e-mail described this upcoming event in the past tense, and
she asked if there had been another immediate jeopardy event to
which she was not aware.
MR. WALL replied that he was not aware of another immediate
jeopardy event.
CO-CHAIR SPOHNHOLZ shared that she was somewhat confused that,
in the e-mail of January 22, an event was described in the past
tense which did not happen until the following week.
MR. WALL replied that he would need to review the timeline.
CO-CHAIR SPOHNHOLZ said "it seemed unusual to me."
4:32:15 PM
MR. WALL directed attention to slide 32 "Documents," which
listed a link to any requested documents.
4:32:50 PM
REPRESENTATIVE CLAMAN asked why the January emergency, which
resulted in the immediate introduction of outside management
with a short-term contract through the end of June, also
resulted in a non-competitive bid process for the best services
starting July 31 with this same outside management group. He
declared that he was "troubled by that."
MR. WALL replied that the decision had been made for
privatization with an emergency provider to solve the problem in
two phases. Phase 1 had the aforementioned three deliverables
attached. He explained that the decision to hire a contractor
was done under AS 47.32, and he pointed to a summary statement
issued by the Attorney General's office explaining the stance
from this statute. He referenced the statute which stated that
in cases of immediate harm or immediate jeopardy to a patient in
the facility, the commissioner could step in "in a temporary or
permanent fashion." He continued to explain that "after years
of instability and inability to meet mission" an organization
was brought in to stabilize, bring the organization back to full
compliance, and provide care in its full capacity in a short
period of time. He questioned why, after this had been
accomplished, would the Department of Health and Social Services
(DHSS) risk de-stabilizing that. He explained that the contract
had been designed in two phases to ensure meeting the mission in
the first phase and to "roll into the stabilization in the long
term in the second phase." He declared that the desire of DHSS
was to provide continuity and stability for the system and the
hospital over time.
4:36:05 PM
REPRESENTATIVE CLAMAN pointed out that the decision for
stabilization with only one option to provide the best
management to go forward was made between January 29 and
February 8, the date of the signing of the contract [with
Wellpath Recovery Solutions]. He emphasized that this was "a
very, very short period of time." He offered his belief that
during this time there had not been any discussion with groups
other than Wellpath Recovery Solutions.
MR. WALL, in response, said that this decision was made after
determination for the speed at which other providers could
arrive. He declared that "the conversation was not small or
quick in the commissioner's office" and he listed the other
participants in the decision making for how to proceed, what was
the best course of action, and what best protected and provided
care for the patients and staff. He stated, "that was the
decision that was made."
REPRESENTATIVE CLAMAN asked for the date on which the formal
decision was made to move forward with a single source contract
and not to go through a procurement process for the services
beginning on July 1.
MR. WALL said that he would get that date. He explained that
the situation appeared very similar to another immediate
jeopardy issue in Alaska, in which the commissioner [Department
of Health and Social Services] had intervened in this exact way,
hence the decision was made at that point. He reported that
there were "a lot of long hours and much discussion" before the
decision was made.
4:38:59 PM
CO-CHAIR SPOHNHOLZ opined that the primary criteria for the
selection of Wellpath Recovery Solutions was "their ability to
come in and take over operations of API immediately." She asked
if there were other criteria reviewed, as well.
MR. WALL paraphrased the criteria listed on slide 31, which
read:
Was available immediately;
Had specific inpatient psychiatric experience
including both civil and criminal commitments;
Has a team of nationally recognized experts that has
the experience and track record to bring noncompliant
hospitals back into compliance rapidly.
MR. WALL declared that this was a very difficult set of
expertise to find.
CO-CHAIR SPOHNHOLZ reported that about 23 other national
corporations performed this type of work. She declared:
it seems highly unlikely that this is the only choice
we could have pursued, and that it's highly atypical
to take a specific emergency event to issue a contract
which essentially obligates the state to over $88
million in contract without any transparency or
competition in the process, particularly when we're
talking about operating an institution that cares
for... our most vulnerable people in the State of
Alaska.
CHAIR SPOHNHOLZ expressed concern that there was not a review of
other providers when considering this extremely important
responsibility with API.
MR. WALL acknowledged the concern and reiterated that, as there
had been previous discussion with three organizations, when it
became necessary to move rapidly when the immediate jeopardy was
discovered, they were aware that Wellpath Recovery Solutions
could be there quickly.
CO-CHAIR SPOHNHOLZ offered her belief that it was extremely
atypical to issue a sole source contract for a project that was
so important. She pointed out that in the public sector there
were rules for transparency in the competitive bid process.
These required review of a broad range of performance metrics
and financials before undertaking a contract of this size. She
pointed out that the only performance metric was for API to
operate at full capacity and remain accredited. She opined that
there was no incentive in the contract to ensure a safe, trauma
informed, and therapeutic environment. She asked that Mr. Wall
address the concern that there were not any other performance
metrics in the contract.
MR. WALL reported that the three metrics in the contract were:
to ensure the safety and security of staff and patients; to
bring the organization back into rapid compliance; and to
prepare for the opening of all 80 beds by July 1. He stated
that those metrics were in the contract, adding that safety
meant a reduction of assaults, seclusion, restraint, and harm
and that those needed to be evident. He explained that bringing
the organization back into compliance with the regulatory bodies
meant that it was necessary to have the plans of correction in
place and have them as an accepted practice to all the
regulatory bodies. He added that it was also necessary to bring
the organization back to full capacity.
CO-CHAIR SPOHNHOLZ stated that these agreements should be in the
contract and possibly in a service level agreement. She asked
if there was a service level agreement with the contract.
MR. WALL said that the second phase of the contract was being
worked as they moved forward, and that the contract would
"definitely have one."
CO-CHAIR SPOHNHOLZ commented that, typically, in the public
sector with such an important responsibility in caring for the
most vulnerable and the use of state resources, it was required
to have transparency in this entire process. She stated that
the details of a contract should be determined earlier in the
process, with a competitive bid process. She expressed her
concern whether this was the best possible product resulting in
the best possible care for the patients at API. She emphasized
that "the striking lack of transparency in this process concerns
me."
4:45:38 PM
REPRESENTATIVE JACKSON asked whether Phase 2 would offer the
option for other partnerships.
MR. WALL replied that Department of Health and Social Services
and Wellpath were "definitely moving towards partnership with
other organizations." He added that this could not be done
without partnerships and "we will continue to seek them."
REPRESENTATIVE JACKSON asked to verify that Wellpath would work
with other institutions and organizations to ensure that the
patients at API would get everything they needed.
MR. WALL replied that there were many partners throughout Alaska
to ensure in-patient psychiatric care, although API was the most
visible and the most volatile piece of this care system. He
stated that the partnership "that cares for patients
appropriately across the state needs to be built in a ...
broader capacity."
4:47:24 PM
CO-CHAIR ZULKOSKY directed attention to the procurement document
which indicated a June or July time frame for the Department of
Health and Social Services to assess whether to continue to work
with Wellpath. She shared that her discussions with Wellpath
executives indicated that, for a proper transition, the decision
would need to happen by mid-April. She offered her belief that
it was not possible to accomplish all the agenda milestones
outlined for Wellpath by this time. She asked how the
department was handling this.
MR. WALL replied that the evaluation for whether Wellspring had
met the terms of their contract needed to be made by April 15.
If Wellspring was going to be successful in Phase 2 of the
contract, it would be necessary to have the staffing in place to
meet the terms of the contract. He stated that Wellspring would
need to begin hiring and licensing staff prior to June 30 in
order to move into the second phase. He explained that some of
the dates were for hiring and some were for the evaluation
process.
CO-CHAIR ZULKOSKY asked about the date for Department of Health
and Social Services to make a determination whether to continue
the contract with Wellpath.
MR. WALL replied, "April 15."
CO-CHAIR ZULKOSKY expressed her concern for such a large amount
of work in such a short period of time, and that "it seems
incongruent for the department to be able to make a decision by
then." She asked for an explanation to the logic for this
rationale.
MR. WALL echoed her concern for the workload, noting that there
was a tremendous amount of work to be done prior to April 15.
He declared "the reality is we need to have a point at which we
can evaluate the progress towards meeting the goals" and
contractual obligations prior to a date for Wellpath to build
the necessary staff. He noted that the decision point had to
allow Wellpath enough time to hire, license, and place staff and
ensure meeting the goals.
CO-CHAIR ZULKOSKY opined that the decision to move forward with
Wellpath had been made regardless of the outcome of the goals
outlined in the procurement documents.
MR. WALL added that the contract also included a 30-day out-
clause which he described as an evaluation point between the
State of Alaska and the contractor. He said that there was an
on-going consistent evaluation of progress performed on a daily
and weekly basis. He reported that there were a complex number
of plans of correction and points on each of those plans of
correction that needed to be fixed and addressed in a
substantive way between now and the time stated for compliance.
He explained that, as each individual requirement had to be
tracked, "there's a heavy lift of work to be done." He said
that for the goals to be attained, it was necessary to have a
period of time for commitment to allow for staffing to provide
the care necessary to move forward.
4:52:31 PM
REPRESENTATIVE TARR expressed her discomfort as the decision
point was too early in the process to be able to evaluate
success, which prevented Department of Health and Social
Services from looking at other opportunities. She said this did
not allow enough time "to see if this is the right thing to do."
She pointed out that there was proposed legislation to prohibit
the privatization of API, as well as the budget issue, and that
neither of these would be accomplished prior to April 15. She
opined that this would put more pressure on an already stressed
situation, which could be unproductive and uncomfortable.
MR. WALL said that he also felt an immense amount of pressure
for the complexities of moving forward in this situation. He
shared that, as the perspective was for a mutual commitment
between the state and the contractor, the contract was designed
in a way for the state to commit to the contractor on a
substantive level so the contractor could commit the resources
to build success into the system. He stated that a half-hearted
approach was "doomed for failure." He pointed out that the
liability for the state with this issue required a significant
investment of time and money moving forward. He added that the
state continued to build relationships with partners and
continued to look for solutions, noting that the contract
offered a 30-day window for evaluation. He said that April 15
was a turning point which allowed the ability to commit
investment of resources, while also allowing the 30-day window.
4:56:12 PM
REPRESENTATIVE PRUITT reminded that there was a specific reason
for the July 1 date in Phase 2.
MR. WALL explained that the state was under provisional license
regarding the issues at API until June 30. He pointed out that
after that date the problems did not go away as there was still
an iterative process for correction to many years' worth of
issues.
REPRESENTATIVE PRUITT highlighted that there had been
recognition of a problem with API during the past year. He
reported that this had not been a snap decision, but that the
January 29 issue had forced immediate action. He stated that
there had been a disservice to the people being served. He
declared that we were not serving the people who API was
supposed to be serving. He said that it was a moral
responsibility to take action immediately.
MR. WALL expressed his agreement that there had been warning
about this crisis, which could not be addressed by a small and
normal change. He acknowledged that there was a moral and
financial crisis and that it was his obligation to meet both.
He relayed that "sometimes you call the shot and you do your
best as a group, as a team, to answer a specific need."
5:00:43 PM
CO-CHAIR SPOHNHOLZ expressed her agreement that something
seriously needed to be done at API, and she asked to return to
the process for how to address the issues. She pointed out that
there had to be a written feasibility study when bringing any
changes to the collective bargaining agreement with the
employees. She reported that there had been an earlier study
for privatization which had found that there were not any
savings or better outcomes, so there was a decision to "stay the
course." She asked about the status of the required feasibility
study.
MR. WALL said that there was intent to have the previous
feasibility study updated. He pointed out that it had first
been done in 2016 and published in 2017, and that "much has
changed since then." He noted that the beds were closed at API
after that study. He said that they intended to have this
completed study within the 30-day contractual obligation with
the partner unions.
CO-CHAIR SPOHNHOLZ asked if this was a realistic time frame and
would it affect the deadline for a decision point with Wellpath.
MR. WALL expressed his agreement that it was an "incredibly
tight turn around." He reported that the organization which had
previously done the feasibility study felt they could "turn it
around quickly."
5:04:07 PM
REPRESENTATIVE TARR expressed agreement that this was an ongoing
problem. She stated her hope that a lesson had been learned
with the forced resignation under partisan political pressure of
two of the top employees at API, which had exacerbated the
problem at a critical time. She emphasized that, as it was hard
to attract and retain these highly skilled positions, politics
should not be played with those important positions.
^PRESENTATION: WELLPATH RECOVERY SOLUTIONS
PRESENTATION: WELLPATH RECOVERY SOLUTIONS
5:05:47 PM
CO-CHAIR ZULKOSKY announced that the next order of business
would be a PowerPoint presentation by Wellpath Recovery
Solutions.
5:06:23 PM
JEREMY BARR, President, Wellpath Recovery Solutions, said that
he would provide information about Wellpath and provide an
update on the progress thus far at API.
DR. KEVIN ANN HUCKSHORN, Senior Consultant, Wellpath Recovery
Solutions, paraphrased from slide 1 "What We Believe," which
read:
Persons suffering from mental illness can and do
recover
Caregivers first priority is to support recovery of
the patients they serve
Patient care should be individualized, trauma-
informed, and evidence-based
Staff are entitled to the training, support and
guidance they need to be effective
Staff and patient safety are interrelated
MR. BARR moved on to slide 2, "Who We Are," and stated that
Wellpath was a health care company providing health care in a
variety of public settings. He reported that they were
organized into three operating divisions: providing health care
to local government entities; providing health care to state and
federal entities; and this entity at API, specializing in
providing inpatient psychiatric and residential treatment. He
added that this division operated at 13 sites in 8 states,
served about 2,700 persons, and had about 3,000 employees.
MR. BARR shared slide 3 "Division Overview" and stated that
Wellpath had experience with a wide range of patient populations
who had been involuntarily committed to a term of treatment
either through a civil or a forensic court process. He pointed
out that each of the programs promoted trauma-informed,
evidence-based, and individualized patient care which was person
centered and focused on individual strengths to help empower
individuals to recover. He moved on to slide 4, "Current
Operations," which depicted the 12 operations currently operated
by Wellpath.
MR. BARR shared slide 5, "South Florida State Hospital," and
reported that Wellpath had a more than 20-year partnership with
the Department of Children and Families in Florida for this 41-
bed hospital.
5:11:09 PM
DR. HUCKSHORN added that there had been a virtual elimination of
restraint and seclusion at that facility. She reported that
restraint and seclusion had been a national issue in 1998, and
the U.S. Congress had called hearings for discussion. She spoke
to the success of the public-private partnership of South
Florida Hospital, noting that the conflict and violence had been
greatly reduced and the patient participation in treatment
programs had increased. She stated that there was more
effective work toward patient discharge. She reported that
there was 98 percent patient satisfaction as measured by
confidential surveys and grievances.
5:14:42 PM
REPRESENTATIVE TARR directed attention to the Florida Civil
Commitment Center referred to on slide 4 and asked why the
website listing was for Correct Care Recovery Solutions. She
asked about the relationship between the two companies.
5:15:15 PM
MR. BARR, in response to Representative Tarr, explained that it
was the same legal entity although there had been a name change
from Correct Care Recovery Solutions, now renamed Wellpath
Recovery Solutions.
5:15:36 PM
MR. BARR shared slide 6, "Bridgewater State Hospital," and spoke
about the history of the hospital prior to its management by
Wellpath in 2017.
5:16:55 PM
DR. HUCKSHORN detailed her involvement with the Bridgewater
State Hospital program beginning in 2017.
5:18:23 PM
DR. HUCKSHORN turned to slide 7, "Treatment Philosophy," and
stated that the "treatment philosophy basically lays out our
values" and that these values became the template to measure.
She paraphrased from the slide, which read:
Recovery model ? Trauma-informed care ?
Interdisciplinary, holistic approach ? Effective,
evidence-based programs ? Culturally relevant ?
Integrated treatment of co-occurring disorders ?
Collaborative safety planning
DR. HUCKSHORN continued with slide 7, stating that the patient
had to be included in the development and the implementation of
the plan of care. She added that when untreated, psychosis
patients lose brain function which would not be regained. She
said that it was necessary to respect cultural differences and
viewpoints. Medicine has moved from "let's hope this works" to
evidence and results-based practices. She reported on the loss
of fundamental civil rights of American citizens who enter a
psychiatric hospital, which makes them completely dependent on
staff to meet their needs. She declared that an environment of
care, with respect and dignity, was critical to a successful
treatment process. She concluded by stating that safety was the
responsibility of everyone, from the CEO through the janitor,
and included the people served. She stated that it was
necessary to create a safe community of people working together
to keep everyone safe.
5:26:27 PM
DR. HUCKSHORN shared slide 8, "Minimizing Abuse, Neglect, and
Exploitation." She paraphrased from the slide, which read:
Zero tolerance for abuse, neglect, and exploitation
including sexual misconduct ? Allegations promptly
reported and referred for investigation ? Staff
receive training when they are hired and annually
thereafter ? Patient Advocate and Peer Specialists
ensure patients have opportunities to safely report
incidents
5:28:39 PM
DR. HUCKSHORN moved on to slide 9, "Culture of Safety," and
stated that this was the number one priority for Wellpath. She
highlighted that it meant immediate failure if "the people we
serve do not feel safe in the environment where they're getting
treatment, and we also fail if our staff do not feel safe." She
paraphrased from the slide, which read:
Communication ? Collaboration ? Safety Surveys ?
Trainings ? Quest Rounds ? MANDT System
5:31:58 PM
MR. BARR added that with inherently unpredictable behaviors
associated with these populations, there will be critical
incidents so that reporting and documenting becomes paramount.
He shared that Wellpath had invested in a program that
documented incidents and allowed for the data to be compared and
assessed for appropriate triage.
5:33:12 PM
DR. HUCKSHORN moved on to slide 10, "Restraint and Seclusion,"
which she deemed to be "quite close to my heart." She shared
her background and referenced an incident in which a child had
died in restraint in Hartford, Connecticut. That death led to
hearings in the U.S. Congress, resulting in a change in the
rules and regulations for the use, monitoring, and documentation
of seclusion and restraint. She and her colleagues had
developed evidence-based practice known as "the six-course
strategies to prevent conflict and violence in behavioral health
in-patient settings." She pointed out that many of the
strategies were a result of learnings from her work at Wellpath
and that the program had since been implemented in all the
Wellpath facilities. She directed attention to the graph on the
slide which depicted "Hours of Restraint Per 1,000 Patient
Hours" in five different facilities, noting that the two
Wellpath facilities scored much better than the national
aggregate. She reported that Wellpath strongly believed that
seclusion and restraint was dangerous, it could hurt and kill
people, and it was traumatizing; hence, this action was avoided
at all costs.
5:36:20 PM
DR. HUCKSHORN, in response to Representative Spohnholz,
clarified that this was the Nashgood [indisc] Research Institute
Weighted Average for 200 of the Joint Commission State
Hospitals.
5:36:36 PM
REPRESENTATIVE TARR asked how Wellpath had been able to achieve
such a contrast to other facilities. She asked if this was a
result of more professionalized treatment for the individuals
with a serious mental illness.
5:37:46 PM
DR. HUCKSHORN answered "it's complicated, because violence is
complicated, and has multiple variables." She offered her
belief that the only way for success was with a significant
culture change that begins at the very top of the organization
with specific policy statements from senior leadership. She
reported that there had been a decision to only use restraint
and seclusion "in the face of imminent danger and as a last
resort." She added that no one would be left in seclusion and
restraint, and after the incident, there would be "rigorous
debriefing." She stated that it was necessary to create
environments of care and avoid conflicts in order to not have to
use seclusion and restraint. She spoke about the necessity for
the shifting of "unwritten rules" because so many fundamental
human rights were stripped from individuals when they entered
the hospital. She relayed that it was important to always
remember that "we are much more similar to the people we serve
than we are not." She reported that Wellpath did "really good
risk assessments" for trauma history, treatment intervention,
remission history, anger management, sensory modulation, and
violence risk. She spoke about immediate safety planning with
new patients. She noted that there was also rigorous de-
briefing to avoid future issues.
5:43:44 PM
MR. BARR, in response to Representative Claman, explained the
lines on the graph on slide 10, noting that the grey and the
green lines disappeared on the graph as they were zero.
5:44:46 PM
MR. BARR introduced slide 11, "What Does Success Look Like?" He
paraphrased the slide, which read:
Compliance with all regulatory agencies ? Services for
up to 80-beds ? Increase staffing complement ?
Improvements in the therapeutic milieu ? Reduction in
grievances ? Improved linkages within continuum of
care ? Reduction of seclusion and restraint ?
Reduction in assaults ? Community-based Governing
Board ? Improved communications and collaboration with
stakeholders
MR. BARR said that they had met with stakeholders to better
understand and strategize for how to integrate and operate in
Alaska.
5:48:53 PM
REPRESENTATIVE CLAMAN noted that Wellpath was recommending a
community based governing board, and asked if there would be
proposed legislation from the administration for consideration
of this.
5:49:13 PM
MR. WALL clarified that there were existing by-laws for the
hospital and that the governance board, and its make-up was part
of those by-laws. He reported that this make-up was being
amended to match the Wellpath message and he offered to share
the board members.
REPRESENTATIVE CLAMAN suggested that there had been a loss of
confidence in the process, and the absence of a community
governing board being actively involved in API. He asked if the
administration would consider putting this into statute to
specify its continuing existence and who served on the board, so
this would not be lost in regulation.
MR. WALL expressed, "we could certainly look at doing something
like that. I'm not sure what all that would require."
5:50:44 PM
CO-CHAIR SPOHNHOLZ acknowledged that they had checked "a lot of
boxes for me in terms of talking about the way it is that you
treat the people that you care for, the way that you develop
your staff, you build your team," although there were still some
pieces missing, which included an external governing board and
clear standards for performance. She asked if Wellpath would be
willing to amend the contract to include performance metrics and
accountability.
5:52:21 PM
MR. BARR replied, "yes, absolutely." He relayed that the idea
for associated performance measures and oversight in the form of
audits were welcome.
5:53:01 PM
CO-CHAIR SPOHNHOLZ shared that there was an additional concern
for how the State of Alaska can be confident about the Wellness
health and safety record. She reported that a quick Google
search on the web revealed some concerning reports and lawsuits
with findings. She listed some of these findings to include
trafficking of medications and overmedication of patients. She
pointed out that these preceded Wellpath in its reputation and
brought concern when "handing over care of our most vulnerable
people." She asked for a response on the record.
5:54:14 PM
MR. BARR addressed the trafficking of medications and pointed
out that this had been by a contracted pharmacy relationship
with a consulting agreement, and the contract had been
immediately terminated. Subsequently, the pharmacy role was
brought in-house. Regarding quality of care, he stated that
these were challenging health care environments with occasional
adverse outcomes. In 95 percent of the time, these outcomes
resulted from a single individual acting outside of policy and
procedure. He reported that there had been an immediate action,
with the individual placed on administrative leave without pay
while there was an investigation by their Office of Professional
Responsibility for determination. Pending the results of the
investigation, there was a range of progressive disciplinary
options, up to and including termination. He continued and
explained that there was a longer-term action to address these
situations in order to minimize the likelihood for a recurrence.
He reported that there had been discrepancies between the
documentation and the video footage, so they invested in
technology that allowed tracking for accountability. He
described the technology.
5:58:35 PM
CO-CHAIR SPOHNHOLZ applauded their use of a systemic strategy to
address safety, although it appeared that there could still be
challenges remaining. She asked them to address the six
wrongful death lawsuits at the RISE Program in Colorado as of
October 2018, noting that this still raised serious concerns for
her.
5:59:11 PM
MR. BARR offered a point of clarification, pointing out that
this program was in the Arapahoe County Sheriff's office. In
2013, Wellpath Recovery Solutions entered into an agreement with
the Office of Behavioral Health to provide services similar to
those provided at the state hospital. He pointed out, as there
was litigation surrounding people in jails, the treatment could
then be brought to the individuals rather than wait for a bed at
the hospital. Independent of that, the health care services
were being provided by a local health care component and the
incidences were related to that program and not to the Rise
Program.
REPRESENTATIVE SPOHNHOLZ asked if another provider was
responsible for those deaths.
MR. BARR said that the wrongful death lawsuits were not
associated by the care delivered by Wellpath Recovery Solutions
in association with the Rise Program in Colorado.
6:00:42 PM
MR. BARR moved on to slide 12, "Phase 1 and Phase 2 Goals." He
paraphrased from Phase 1, which read:
Assess current operations ? Regain compliance with all
regulatory authorities ? Provide training to improve
patient care and staff safety ? Train on trauma-
informed care and de-escalation techniques ? Recruit
key leadership team ? Improve communication among
leadership and staff ? Improve communication with
community stakeholders
MR. BARR directed attention to Phase 2, the more active
transition, and paraphrased slide 12, which read:
Maintain compliance with regulatory authorities ? Hire
staff to fill vacancies ? Prepare to increase capacity
to 80 beds ? Implement a culture of safety ? Increase
active, evidenced-based treatment programming ? Reduce
seclusion and restraint ? Engage families ? Improve,
build, and maintain strong community relationships ?
Improve integration of API within the continuum of
care
6:01:42 PM
CO-CHAIR ZULKOSKY directed attention to the dates for Phase 1,
identified as February 8 - June 30, 2019, in the contract with
Wellpath and the State of Alaska, which stated: "during the
start-up phase the contractor shall take all actions reasonably
necessary for API to be in full operation and capable of serving
patients by June 30, 2019." She said that Phase 2 was
identified to begin July 1, 2019 - June 30, 2024, and she asked
for Mr. Barr to share his understanding of the contract beyond
April 15. She questioned how April 15 could be a point in time
for a decision on this contract moving forward for an effective
date that was written into the contract beginning July 1, 2019.
6:02:35 PM
MR. BARR apologized for any confusion from the dates on the
slide, as they were not meant to represent any contractual
terms. He explained that the dates reflected the mechanics
associated with the hiring process that dictated an amount of
time for onboarding staff. He noted that there was an eight to
ten-week process for each person hired to be ready to go on July
1.
6:04:36 PM
CO-CHAIR ZULKOSKY asked if it was Mr. Barr's understanding that
the contract for Phase 2 would likely move forward if they began
active transition on April 15.
6:04:45 PM
MR. BARR replied that it was his understanding so long as
Wellpath continued to provide the services and meet the
expectations of Department of Health and Social Services in
terms of preparation. He said if Wellpath failed to fulfill its
obligations, there was a 30-day termination clause.
6:05:10 PM
CO-CHAIR SPOHNHOLZ asked when Wellpath had been invited to
submit its contract.
MR. BARR replied that he was not aware of the exact date, but he
would get it to her.
CO-CHAIR SPOHNHOLZ directed attention to the provision in the
contract which stated that it was subject to appropriation. She
reported that Department of Health and Social Services had only
requested $33 million, as the state was "facing a very
challenging budget structure" and it was necessary to make very
tough decisions for which basic services could be provided. She
offered her understanding that the proposed Wellpath contract
obligated the State of Alaska to $44 million if API operated at
full capacity. She asked what the decision point from Wellpath
was for pulling out of a contract if there was not the necessary
appropriation to fully meet the contract obligation.
6:06:35 PM
MR. BARR explained that, as Wellpath contracted exclusively with
government entities, these appropriation clauses were in most,
if not all, of their contracts. In the event there was not an
appropriation, Wellpath would review the situation and see what
other options existed. He stated that he could not offer a firm
answer without knowing more specifics. He declared that
Wellpath was committed to doing the right thing, that they had
had success in other circumstances, and they believed that the
plan presented what was necessary for success.
6:07:18 PM
MR. BARR announced slide 13, "Recruitment," noting that Wellpath
had about as many employees as the State of Alaska; however,
the key difference was that Wellpath only focused on recruiting
and employing health care professionals. He cited the shortage
of psychiatrists in Alaska and nationally and explained that
psychiatrists were now a part of their recruitment team. He
stated that the vast majority of the "line staff" would be hired
from the local Alaska work force as it was not practical to
recruit outside a given state. He pointed out that Wellpath had
often partnered with universities to fund placements. He
declared that the first priority was retention.
6:11:03 PM
The committee took an at-ease from 6:11 p.m. to 6:12 p.m.
6:12:33 PM
DR. HUCKSHORN turned attention to slide 14, "Accomplishments,"
and paraphrased from the slide, which read:
Deployed team to API within 72 hours of contract
execution ? Assisted with responses to the Plans of
Correction to the Centers for Medicare and Medicaid
Services (CMS), The Joint Commission (TJC), and other
bodies ? Conducted MANDT presentation to introduce new
de-escalation training for direct care staff ? Met
with API Governing Board members and other
stakeholders, including ASHNA, ABHA, AMHB/ABADA, NAMI
Anchorage, et al ? Partnering with South Central
Foundation to provide cultural training for staff ?
Began staff training in trauma-informed care, patient
rights, and restraint and seclusion ? Held multiple
all-staff town hall meetings to ensure communication
and transparency to API staff ? Implemented weekly
meetings with API leadership ? Implemented safety
huddles ? Began recruiting for consultant positions to
support key management positions
6:17:28 PM
DR. HUCKSHORN moved on to slide 15, "Staff Feedback," and
reported that the staff at API were a "committed, professional
group of staff that really seem to care about what happens to
that facility." She praised the staff's dedication and loyalty
to API.
6:18:23 PM
CO-CHAIR SPOHNHOLZ thanked Dr. Huckshorn for recognizing the API
staff. She stated that the staff needed leadership, training,
and support. She cited her concerns with the privatization of
API regarding staff compensation and benefits, and asked for a
statement on the record as to how they intended to handle that.
6:20:11 PM
MR. BARR replied that no one would go backward in pay. He said
that there were a number of areas where staff were currently
underpaid, which he opined was part of the problem. He said
that Wellpath would look at a compensation analysis and address
the unfairness of new hires being paid more than veterans. He
stated that there would be an equitable treatment of staff.
Regarding benefits, Wellpath offered a retirement plan with a
401(k) and a company match, as well as health, life, and dental
plans. He pointed out that there was no waiting period for
benefits. He declared that staff tenure would be recognized.
6:21:45 PM
CO-CHAIR SPOHNHOLZ asked about the cost for the State of Alaska
to buy out peoples' retirement in order to make this transition
successful.
6:22:21 PM
CO-CHAIR ZULKOSKY recognized the people who had been invited to
testify and asked that they provide written testimony.
6:23:33 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 6:23 p.m.