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Rare three-agency audit of western Colorado mental health center finds dangerous prescription practices

Mind Springs Health, which provides mental health services and has a psychiatric hospital in Grand Junction, remains on a corrective action plan

Summit County Sheriff Jaime FitzSimons doesn't mince words in his criticisms of Mind Springs Health. He has yanked its contracts to provide crisis response in his community and mental health services in his jail. (Photo by RJ Sangosti/The Denver Post)
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State officials blasted one of Colorado’s 17 community mental health centers for prescription practices they called “scary” and “appalling” as they released a rare, three-agency audit Thursday. 

The audit of Mind Springs Health, the safety-net mental health center for 10 counties on the Western Slope, followed dozens of complaints about the quality of care from patients and local officials. 

The 22-page report was the culmination of a review launched in January by the Colorado Department of Health Care Policy and Financing, the state Department of Human Services and the state Department of Public Health and Environment. 

Besides the dangerous prescription issues, the audit said Mind Springs is failing to meet the community need for mental health services. Mind Springs leadership, the audit said, “was not able to articulate or share documented metrics on community access to service gaps, nor produce plans to address those access gaps.”  

Also, the Mind Springs board structure is “complex, lacks transparency” and “limits community engagement,” auditors wrote. Some board members, they wrote, “may have conflicts of interest.” 

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Patients were prescribed multiple controlled substances, including stimulants and benzodiazepines, at high doses, increasing the potential for overdose and addiction, auditors found. Investigators noted a practice of prescribing high doses of sedatives, including Seroquel, without monitoring or documenting patients’ levels of sedation. 

Also, Mind Springs failed to communicate with patients’ other health care providers to make sure that patients weren’t taking a dangerous combination of prescriptions. And the mental health center failed to perform drug screens or use the statewide prescription drug monitoring program to guard against overdoses, the audit says.

The troubles for Mind Springs began in April 2021, after an employee reported concerns about medication mismanagement and other treatment practices, according to the audit. The state regional contractor that handles Medicaid billing and reimbursement for the mental health center suspended payment for new admissions in April 2021 while it investigated the complaint, soon discovering an “aberrant prescriber” who was putting patients at risk. That prescriber was put on leave and Mind Springs was placed on a corrective action plan by the state contractor, Rocky Mountain Health Plans. 

“What we found was quite concerning and it was appalling in some cases,” said Patrick Gordon, the CEO of Rocky Mountain Health Plans. “Prescriptions were being written in a way that could cause problems or patient harm. There were some really serious gaps in oversight.”

That initial investigation, which originated from a whistleblower, included a review of medical records for 112 patients, including prescriptions, discharges and case management documentation. 

A report from the state contractor that was shared with state officials — but not the public — in June laid out “serious issues regarding aberrant prescribing” as well as concerns about hospital discharge protocol and post-release follow-up. Kim Bimestefer, executive director of the state Department of Health Care Policy and Financing, said the June letter was “scary, to say the least.”

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During the next few months, as Mind Springs began working to address the corrective action plan, the contractor received 47 additional complaints about the care provided by the center’s mental health clinics and its Grand Junction psychiatric hospital, West Springs. 

Rocky Mountain Health Plans then went deeper into its investigation, reviewing patient records going back to 2018. Out of 472 records, 68 revealed “severe patient risks” and 60 others included “moderate risks to patient safety.”

The additional findings led to the three-agency investigation, which was announced in January. 

That announcement came soon after a December Colorado News Collaborative investigation that found local officials — including the Summit County jail — were ending contracts with the mental health center. Public officials and local residents said the center has failed to help needy people in mental health crises and that its leadership was not publicly accounting for how it spent tax dollars. 

The mental health center, which serves residents from Summit County to Mesa County, gets public funding, mainly from the state Medicaid program, to care for needy people who are covered by Medicaid, are underinsured or lack insurance. Colorado’s 17 community mental health centers receive $437 million per year in tax dollars and have come under scrutiny recently from lawmakers and behavioral health officials who have questioned the system’s lack of oversight. 

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Problems with the centers — including complaints from people who say they or their relatives didn’t receive help — are a key reason Colorado lawmakers passed major reforms this year to the state’s behavioral health system. A new Behavioral Health Administration will have oversight of what is now a fractured mental health care system

Mind Springs remains on the corrective action plan put in place nearly a year ago. 

The plan requires the mental health center to update policies for safe prescribing practices, including monthly reporting requirements and adoption of a program called OpiSafe, which helps doctors prevent abuse of opioids, benzodiazepines and other drugs. 

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Mind Springs also must expand its board to include people served by the mental health center, and must post notice of its board meetings and allow time for public comment. The plan also requires the community mental health center to better track patient treatment and outcomes — including phone calls, emails and walk-ins requesting appointments — to make sure patients are receiving timely service. 

Mind Springs officials attended a virtual meeting with news media and local officials from the Western Slope on Thursday but did not speak. 

“The bottom line is that a significant amount of progress has been made,” said Gordon, from Rocky Mountain Health Plans. “Many gaps have been closed. But the quality-of-care review is ongoing because there’s more work to do at Mind Springs.”

Mind Springs provides services in Eagle, Garfield, Grand, Jackson, Mesa, Moffat, Pitkin, Rio Blanco, Routt and Summit counties.


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