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Grand Junction mental health center accused of prescription errors that threatened patient safety, report says

A June letter not released until now says Mind Springs put patients at risk

By Susan Greene, Colorado News Collaborative, and Chris Osher, The Gazette

A pattern of “severe, life-threatening” prescription errors by the troubled mental health center responsible for serving 10 Western Slope counties put many of its patients at risk, according to the findings of an official investigation that state agencies withheld from the public for more than nine months.

State officials kept the June findings secret despite mounting public concerns about the Grand Junction-based Mind Springs Health and its psychiatric hospital, West Springs.

The problems were so acute that the state’s Medicaid contractor would not authorize payment for newly admitted hospital patients for three months until Mind Springs agreed to make wide-ranging changes.

The state’s investigation found that of a sample of 58 Mind Springs outpatient clients, nearly half received a quality of care so poor that it was categorized as having potentially “severe, life-threatening impact.” Two people died, although the deaths were not directly attributed to the care they received.

“If there are things being investigated there and problems being found, the public has a right to know,” said Wendy Wolfe, a Summit County resident whose son has been treated by Mind Springs for more than seven years. “Without public disclosure, how else do we know it’s safe to send our families, our community there?”

The Colorado News Collaborative obtained a June 2021 letter written by Rocky Mountain Health Plans, the private company Colorado’s Department of Health Care Policy and Financing contracts to manage and pay Medicaid benefits on the Western Slope. As part of that contract, the company is among those responsible for investigating complaints about Mind Springs and two other Western Slope community mental health centers, and for holding them accountable.

Based on information it received from a whistleblower physician within Mind Springs, Rocky Mountain Health Plans launched its own inquiry last spring.

The letter to Mind Springs’ chief medical officers shows that Rocky Mountain Health Plans’ investigation last spring found nearly half of a sampling of 54 patients at West Springs had received deficient care. Those patients were readmitted to the psychiatric hospital within 30 to 60 days of having been released between February 2020 and February 2021.

Mind Springs drastically cut outpatient services after it opened a new $34 million psychiatric hospital in December 2018 that doubled its inpatient beds from 32 to 64. It now spends nearly three times more on hospitalizations than other community mental health centers and its patients are readmitted at four times the rate, payment data show.

“If you look at the data, look at readmission rates and follow-up after patient discharge…Mind Springs Health continues to be, at the hospital, off the charts compared to other psychiatric hospitals,” David Mok-Lamme, a Rocky Mountain Health Plans executive, said during a recent town hall meeting in Mesa County. “We’re talking multiple times readmission rates and a fraction of the follow-up rate.”

The company’s June 2021 letter shows that, of a sampling of 58 outpatient clients prescribed high doses of the tranquilizer benzodiazepine between February 2020 and February 2021, there were concerns about the quality of care given to 52, and 28 (48%) received care so poor they faced “severe, life-threatening impact.”

An elderly Mind Springs patient who later died was discharged from West Springs hospital with prescriptions for high doses of benzodiazepine and other medications that, when used together, can cause problems with breathing, the investigation found. The man’s death was due to respiratory failure, though the investigation could not definitively link it to improper care. Another patient who received no followup care after being discharged from West Springs died due to an overdose of painkillers. 

Rocky Mountain Health Plans conducted its probe last spring after a Mind Springs physician, the whistleblower, contacted the company about concerns over Medicaid management, prescribing practices, lack of peer review and other treatment problems the whistleblower said were harming patients at Mind Springs facilities.

The Department of Health Care Policy and Financing released the letter detailing Rocky Mountain Health Plans’ findings only after its executive director, Kim Bimestefer, learned that news reporters were obtaining it another way.

Mind Springs is under contract with the state to provide care to people who are indigent or on Medicaid, and to anyone experiencing a mental health crisis in Eagle, Garfield, Grand, Jackson, Mesa, Moffat, Pitkin, Rio Blanco, and Routt and Summit counties.

In Summit County, where the community has been particularly vocal about its dissatisfaction with Mind Springs’ services, officials found its crisis care so deficient that they canceled three contracts with Mind Springs and persuaded residents to pass a new tax to pay for alternative mental health services.

Records show that throughout much of the past year, Mind Springs has remained under a corrective action plan, which requires its facilities to make 17 improvements in protocols to prevent similar life-threatening errors. While many of those changes already have been made, Mind Springs still is finalizing some of the new protocol requirements. 

COLab’s reporting in December prompted the three state agencies with oversight over community mental health centers to launch an audit in January into whether Mind Springs is under-serving the public. The health department found “zero deficiencies,” its records show. 

The Department of Human Services found only administrative problems. Those range from Mind Springs’ failure to report to the state 40% of critical incidents such as prescription errors or injuries within the required 24 hours, to its pattern of releasing patients from its hospital without the proper paperwork for continued treatment.


This story was reported as part of the Colorado News Collaborative, a coalition of more than 160 news outlets across the state, including this one.


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