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

The problems only came to light this month as reporters for the Colorado News Collaborative, including The Gazette, were investigating. 

State officials kept the June 2021 findings secret despite mounting public concerns about the Grand Junction-based Mind Springs Health and its psychiatric hospital, West Springs. ​​Mind Springs patients remained in the dark even though 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 hidden 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 died.

“If there are things being investigated there and problems being found, the public has a right to know,” says 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?” 

As of this writing, state regulatory agencies did not answer reporters’ questions about why they didn’t alert the public to the potentially fatal prescribing errors once last year’s investigation was complete. And Mind Springs executives have not commented about what the findings say about the center’s quality of care.

Mind Springs’ CEO, Sharon Raggio, and two of its other top executives have resigned since December, when the Colorado News Collaborative (COLab) exposed the organization’s long pattern of failing to provide safety-net care for which it is paid tens of millions in state and federal tax dollars each year. 

More concerns came to light this month when reporters uncovered 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 from February 2020 through February 2021 within 30 to 60 days of having been released. 

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 followup 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.”

Mind Springs’ medical staff had prescribed many of those patients high doses of stimulants in addition to their benzodiazepine, which places a patient at risk of overdosing. Benzodiazepine use also is particularly risky for people with substance use disorders. 

The investigation found that two of the outpatient clients in the samping died. Mind Springs and its psychiatric hospital did not have sufficient oversight to detect or prevent what the findings called “aberrant prescribing,” the letter shows.

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 officials, which controls Medicaid funding and holds the contract with company, as well as Colorado’s Department of Human Services – which authorizes community mental health centers and is also supposed to oversee quality of care within them – spent weeks this winter blocking efforts by COLab and The Gazette to obtain information through Colorado’s Open Records Act about the whistleblower investigation and other complaints about Mind Springs.

The Colorado Department of Public Health and Environment, which is responsible for licensing mental health care facilities in the state, has not mentioned on its website Mind Springs’ potentially fatal prescription errors, nor the deaths of two of its outpatient clients uncovered during the investigation. That website was created to give the public access to information about mental health provider prescription errors, fatalities and licensing citations so prospective patients and their families can assess the safety of a clinic or hospital.

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.

For its part, the Department of Human Services has not released documents about the investigation’s findings despite several requests under the state’s open records law and the many times its executive director, Michelle Barnes, has touted her agency’s commitment to ensuring more transparency and accountability in Colorado’s mental health safety-net system. As of this writing, Barnes and Dr. Morgan Medlock – the crisis psychiatrist Gov. Jared Polis recently appointed to oversee that system by leading a soon-to-be-launched agency called the Behavioral Health Administration within the Human Services department – have declined to be interviewed.

The Polis administration’s reticence about revealing and discussing problems at Mind Springs and other community mental health centers comes as mental health care advocates and state lawmakers are questioning state agencies’ effectiveness in overseeing publicly-funded behavioral health care services. As The Gazette recently reported, Colorado’s Legislative Audit Committee this month authorized the state auditor to draft a bill seeking to examine that oversight question and to closely investigate all 17 centers.

The three state departments have long been criticized for overlooking and downplaying problems at Mind Springs and some of the 16 other regional community mental health centers that are supposed to serve as the core of Colorado’s behavioral health safety net. As COLab has reported, the state has given the centers non-compete contracts and a privileged rate status for nearly 60 years, without meaningful oversight, and state officials have a long pattern of caving to pressures by the centers’ lobbying group to avoid closer scrutiny of their operations.

Lawmakers also are debating other mental health care bills, including some to direct the spending of $450 million in federal American Rescue Plan Act funding on behavioral health services and another to set the responsibilities for the Behavioral Health Administration before it launches in June. 

Even though state officials say that agency will serve as the centralized “umbrella” for all things related to publicly-funded mental health care in Colorado, it won’t control most of the funding for community behavioral health care, 82% of which comes through the separate Department of Health Care Policy and Financing. Critics say that means oversight responsibility will still be divided between three departments that have a long history of not communicating. And Coloradans seeking meaningful investigations into how their or their family members’ cases have been handled – as well as members of the public trying to watchdog the state’s mental health system – will still have to navigate a frustrating ask-your-mother, ask-your-father bureaucracy.

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, 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 convinced residents to pass a new tax to pay for alternative mental health services.

Even as problems at Mind Springs were becoming increasingly apparent, state officials deliberately withheld from the public details of last spring’s whistleblower investigation, emails obtained under Colorado’s open records law show. State officials who had been informed of the potentially fatal prescription errors debated how forthcoming they should be about them. On April 19, 2021 Susanna Snyder, a policy official at the Department of Health Care Policy and Financing, noted to Curt Curnow, the department’s quality health and improvement director, that Mind Springs accepts patients from another Medicaid payer, Colorado Access, which serves several counties on the Front Range and Eastern Plains.

“I know they’ve reported to other areas of the state and requested confidentiality during investigation but do we have any obligation in the interim?” Snyder asked in one email, referring to the Mind Springs investigation and whether other payers should be alerted.

Curnow, that same day, emailed back that their agency could note an investigation “is taking place, which the department is closely monitoring.” However, he continued, the department “cannot disclose the details” of the quality of care concern “at this point in time.” Four other Health Care Policy and Financing employees were copied on the communication.

The investigation last spring determined that of the sample of 52 outpatient clients whose treatment was found to have been concerning, one physician was involved in the care of 18, or 35%, of those clients.  

Records show that a psychiatrist, Dr. Thomas Newton, resigned from Mind Springs in May after he was placed on administrative leave due to “aberrant prescribing” practices revealed during the investigation. Newton remains licensed to practice medicine in Colorado, and regulators in charge of physician licensing at the Colorado Department of Regulatory Agencies have posted no details about the controversy over his care at Mind Springs on its online license lookup tool. Newton has not returned telephone calls, text messages and emails seeking comment.

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.

The allegations by the physician who blew the whistle were so serious that in April, Rocky Mountain Health Plans denied Mind Springs payment for new hospital admissions. The halt on payment was lifted after Mind Springs agreed to a corrective action plan in June.

Records show that throughout much of the past year, Mind Springs has remained under that 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.

Additional problems have surfaced since the conclusion of the investigation into aberrant prescribing. 

In December, Rocky Mountain Health Plans notified state health officials that from July 1, 2018 through December 15, 2021, it had reviewed 472 quality of care concerns involving Mind Springs and West Springs. Of those, 251 – nearly 60% – had some validity, with 68 of those – or 16% – found to have posed severe, life-threatening risks to patients. Some of those cases occurred after Mind Springs agreed to corrective actions last spring.

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.  

Rocky Mountain Health Plans, investigating on behalf of the Health Care Policy and Financing department, is still asking questions.

Dozens of current and former Mind Springs employees have come forward over the past few months to describe how they say the organization fails to properly care for patients – and also ignores their humanity.

“I had to put a man in his 70s out on the street in his shirt and diaper in his wheelchair. It was winter time,” says Sarah Mackie, a former admissions coordinator at West Springs, noting she was instructed to do so. “That was the worst. Just the worst. I think about it all the time.”

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