The flurry of action is expected to allow CMHIP to retain its participation in the Medicare program when inspectors from the Centers for Medicare and Medicaid Services (CMS) review the hospital's corrective measures next week. The larger question, though, is why the state didn't respond more vigorously to the understaffing problem — which has festered at CMHIP for months, producing a spiral of sinking morale, resignations, inadequate care and what the regulators term "negative patient outcomes" for some of the most vulnerable, severely mentally ill patients in Colorado — before its Medicare status was threatened.
In fact, there's a sense of déjà vu about the recent shortage, since chronic understaffing has been one source of operational problems at CMHIP dating back years. A 2010 report on the hospital by independent consultants found that CMHIP was then understaffed by as much as 20 percent; that patient-to-psychiatrist ratios were too high and staff morale low; and that the "organizational structure at CMHIP is in disarray."
Rising vacancies in staffing since at least last fall were a principal contributor to the recent CMS finding of immediate jeopardy. An e-mail last October from the chief nursing officer to Ron Hale, then the CMHIP superintendent, noted that the facility had 43 vacant nursing-staff positions; by mid-April of this year, that figure had risen to 93. (CMHIP has a total of 723 "direct care" positions, including licensed nurses, health-care technicians, client-care aides and others.)
The CMS investigation found that the unfilled positions contributed to an array of problems at the hospital, which houses many court-committed patients who are assaultive, suicidal or have acute medical needs. Certain units lacked enough staff to distribute medicine or conduct required group therapy sessions; in April, multiple staff members reported injuries "due to a patient seclusion and restraint incident and not enough staff to run the unit safely." The perception that certain units weren't safe for employees prompted more resignations and complaints.
Hale tendered his resignation as superintendent in the wake of the "immediate jeopardy" finding, but state officials decline to characterize his impending departure, which will be final next month, as related to the federal action. Nancy VanDeMark, the director of the Office of Behavioral Health for the Department of Human Services, says hospital administrators had been working intently on filling staffing holes for months before the feds stepped in, but the state has had difficulties competing for a limited pool of behavioral health workers, who are also in demand at other large health-care institutions in southern Colorado. The state's sizzling economy hasn't helped, either.
"It's a chronic problem, and it's exacerbated by national and state trends," VanDeMark says. "We've tried to keep pace with our recruiting efforts, but we're kind of pushing a ball uphill."
Since the "jeopardy" finding, the state has imposed mandatory overtime requirements on CMHIP staff, restructured shifts to achieve greater efficiencies, canceled a well-received but labor-intensive program for people with co-occurring mental-health and substance-abuse disorders, and expedited hiring processes. "We have fully implemented all of the corrective actions in the negotiated plan," VanDeMark says.
Some of the emergency measures, she acknowledges, will impose greater stresses on morale in the short run. "We have had some resignations in the last few weeks, but we've had a net gain in hires," she says. "We expect as we put these other things in place, the mandatory overtime will go down. We have a core group of committed people who work for us who should be appreciated for caring for some of the most vulnerable people in the state."
VanDeMark's people are looking at a range of options to improve staffing and lower turnover, including mentorship programs and referral and sign-on bonuses. The state has also issued a request for proposals for a consulting firm to review the CMHIP staffing problems, a request that was already in the works before the federal regulators issued their findings.