Thank you for providing a summary of your planned story and affording Cascade Behavioral Health (Cascade) an opportunity to respond with important facts and context about our hospital, the unique and medically complex patient populations we are proud to treat, the overall realities and challenges of behavioral health care delivery and hospital regulatory compliance processes here in Washington State, regionally and across the country.
As we recently discussed, state and federal patient privacy law as well as our organization’s code of ethics severely restrict our ability to offer detailed comment on the specifics of individual patient treatment and incidents. However, we respectfully contend that your current story angle and planned reportage, including extrapolating a small handful of unfortunate, isolated and non-representative incidents (many occurring years ago) has the potential to provide an incomplete and highly distorted representation of inpatient psychiatric treatment in general and Cascade in particular.
Below, we have prepared additional information and perspective that we hope and trust will assist you in producing a more informed, objective and contextualized representation of Cascade that takes into account the totality of our clinical performance and compliance record and the dedicated efforts of our clinicians and staff that work tirelessly every day to help patients improve the quality of their lives in the Greater Seattle community that all of us are proud to call home.
About Cascade: Our Patients, Staff, Mission & Values:
Since acquiring the facility from previous operators in 2012, Cascade and its over 300 dedicated clinicians and support staff have provided high quality, evidence-based, compassionate and therapeutic BH care to over 15,000 patients across 176,000 treatment days. The hospital has at all times since its founding been fully licensed and certified in good standing with all state and federal regulatory and licensing authorities, including the WA Department of Health, U.S. Department of Health and Human Services’ (HHS) and Center for Medicare and Medicaid Services (CMS) and TriCare for which it is a certified provider. It has never been subjected to any licensure restrictions, fines, admission freezes, payment suspensions or facility closure orders.
Contrary to your suggestion about “doubling the number of licensed beds,” Cascade is licensed for, and currently operates, 137 beds, less than the former operator Highline Health’s license of 142. We operate less beds due to the need to convert some patient rooms to group therapy areas more aligned to our BH focused mission.
Cascade provides specialized care to a high-risk population including a specialty geriatric service. These high acuity (aka severe and often chronically ill) patients are living with serious and complex conditions such as depression, bipolar, schizophrenia, psychosis, advanced dementia, substance use disorder and often with multiple significant medical comorbidities such as diabetes, hypertension, obesity, osteoarthritis and heart disease. Many of our patients come to our facility experiencing some of the most profoundly challenging behavioral and medical health challenges of their lives, including being turned away or transferred from other hospitals that are unwilling or unable to provide the highly intensive, specialized services offered at Cascade. Given the complexities, this population is one for which few behavioral health and medical/surgical hospital facilities will provide care.
To this end, many of our geropsychiatric patients are frail, suffer from dementia and struggle to ambulate safely. Cascade consistently employs a variety of comprehensive safety protocols and procedures for these patients, including but not limited to bed alarms, fall sensors and 1-1 observation when deemed clinically appropriate. Despite our best efforts, patients with these conditions do occasionally experience falls. Similarly, patients receiving care at our hospital can also occasionally exhibit aggressive and disruptive behaviors manifesting in occasional aggressive outbursts. Our staff are trained in advance behavior management and de-escalation techniques to minimize such occurrences to the greatest extent possible.
We are dedicated to providing our patients evidence-based, personalized and compassionate care they need to experience true and lasting healing. At Cascade, we understand that addiction and other behavioral health disorders have a profound negative impact on individuals and families. But we also know that with the right type and level of treatment, people who have been struggling with these challenges can achieve a healthier and happier future. This commitment is reflected in our mission and vision statements:
- Mission statement: In every crisis is an opportunity.
- Vision statement: To become a center for holistic healing, well-being, and human potential.
Cascade recruits and employs dedicated, and accomplished clinicians and support staff specifically trained to work with our specialized patient population, including close monitoring of possible condition deterioration, both physical and mental. Nevertheless, the overall rate of serious level incidents at Cascade is under 0.008% per patient treatment day.
Our Chief Medical Officer, Dr. Jeff Skolnick, has led two other large outpatient mental health centers in King County, one of which included a psychiatric hospital for involuntary patients. Further, our geropsychiatrist is fellowship trained with many years of experience, and our staff is skilled, such that they have a trusted reputation with families and a high success rate in returning patients to their previous facilities or to the next level of care. All Cascade clinicians, support staff and administrators understand that we have a solemn duty and responsibility to our patients and their loved ones to provide the highest-level care possible while constantly endeavoring to improve and innovate across all aspects of our operations.
Cascade also maintains laudable patient satisfaction scores based on hundreds of anonymous surveys compiled by respected independent vendor PressGaney. In recent years, nearly 78% of patients described their overall satisfaction as Very Good or Good with similar percentages reporting that they felt more hopeful after receiving care and would be likely to recommend the facility to a friend or family member.
BH Hospital Admission Criteria, Regulatory Compliance & Enforcement Process:
Prior to addressing some of your specific questions to the extent we are permitted, it’s helpful to provide additional background and context on the overall criteria for admission, the regulatory and accreditation oversight system and tiers of alleged deficiencies.
Three main criteria are assessed for any admission to a psychiatric facility such as Cascade, satisfaction of one or more which will justify admission. The first is suicidality – if someone is suicidal, or at significant risk of harm to themselves. The second is whether there is a significant risk that the patient may harm someone else, which is often referred to as homicidality. The third is whether the individual is gravely disabled and/or unable to care for themselves to the extent that their present psychiatric symptoms and diagnosis significantly interferes with their ability to undertake essential daily activities. These admission criteria are uniform across all acute psychiatric facilities including Cascade and the clinical determination on whether to admit any patient is made by the attending psychiatrist in consultation with other members of the clinical support team.
All U.S. healthcare facilities are routinely subject to unannounced visits and detailed inspections (“surveys”) by federal and state regulators as well as independent accreditation organizations such as The Joint Commission or State Department of Health (DOH) with deeming authority from CMS. Incident and deficiency reports, corresponding plans of correction and even occasional notices of potential termination of CMS certification are common aspects of the comprehensive regulatory process governing all hospitals. Regulators and accreditors conduct thousands of inspections annually at hospital facilities nationwide. The surveys, depending on the circumstances, can be triggered by the regulator itself, or in other instances from complaints (whether substantiated or not) from patients, staff and family members as well as the facility self-reporting incidents requiring a survey.
These site visits include, but are not limited to, reviewing current and historic performance data, medical records reviews, facility inspections, patient interviews, employee interviews, staffing sufficiency, and a host of other clinical and environment of care concerns. Regulators and accreditors can and do make unannounced visits with or without cause at any time of their choosing. The central goal of the regulatory process is to ensure that all facilities are compliant with CMS and state licensing regulations and accreditation standards while providing appropriate care to patients. Thousands of facilities nationwide encounter instances of non-compliance in clinical areas sometimes necessitating re-survey, threats of Medicare termination and other more serious remedial and punitive measures.
If a facility is suspected to be non-compliant in a specific area, CMS utilizes a three-tier system to indicate the alleged severity of the non-compliance. Standard-level findings constitute issues a facility must address but which do not jeopardize its participation in federal healthcare programs, usually minor administrative or maintenance matters.
Conditional-level deficiencies are more serious allegations that require a facility to submit a formal plan of correction to CMS. A subcategory of the conditional level is the immediate jeopardy designation. These scenarios stem from findings deemed serious enough that CMS and other regulators can suspend admissions, impose fines, freeze reimbursements and, in rare instances, terminate a facility as a provider and force it to temporarily close and transfer patients.
Alleged patient safety related citations (including immediate jeopardy classifications) do not necessarily equate to a conclusion that any actual patient harm occurred or will occur. Rather, it constitutes a subjective allegation or finding from a particular surveyor(s) that there is potential [emphasis Uradnik’s] for harm. The preparation and submission of plans of correction (even when Cascade may disagree with the substance of the allegation) are designed to reduce the possibility of the potential or actual harm from occurring or re-occurring, the goals of which Cascade strongly supports.
Cascade’s Record of Regulatory Compliance & Adherence to Clinical Best Practices:
As stated above, Cascade is fully licensed, certified and in good standing with all relevant state and federal government regulatory agencies and insurance providers (Medicare, Medicaid, TriCare, commercial providers). Cascade has never been suspended or terminated by CMS or any commercial insurer nor has it ever been subjected to fines or licensure revocations or restrictions of any kind. Cascade is also fully accredited by The Joint Commission, a non-profit organization with a 60-year record of conducting robust accreditation and inspection services on behalf of the federal government.
Cascade also performs above the national average on multiple independently administered, evidence-based clinical quality performance benchmarking programs. These include The Joint Commission’s HBIPS (Hospital Based Inpatient Psychiatric Services) Core Measures and CMS’ Inpatient Psychiatric Facility Quality Reporting Program (IPFQR). The latter includes data from over 1,600 CMS certified psychiatric hospitals and inpatient wards measuring a broad set of clinical practices correlated with improved patient outcomes. These metrics are periodically revised and published on CMS’ Hospital Compare website. The latest numbers are from 2017. Cascade constantly endeavors to improve its aggregate scores and as part of its overall quality assurance initiatives and clinician training programs.
The overwhelming majority of survey inspections (including DOH/licensure, CMS and The Joint Commission) conducted at Cascade over the past 6 years resulted in definitive determinations that our hospital was in substantial compliance with all CMS Conditions of Participation (COP), accreditation and license requirements including several surveys that were 100% deficiency free; which is our consistent goal. Cascade values the survey and certification process as a critical opportunity to receive feedback that can be used to improve upon the already high level of quality care provided including updating protocols and policies to enhance our overall clinical operations.
While Cascade constantly strives for excellence in all aspects of our operations, we are mindful that over the course of treating approximately 3,000 high-acuity patients per year, regrettable and unpredictable events occasionally occur including instances of alleged non-compliance with regulatory requirements and in some cases our hospital’s internal policies. In each of these infrequent situations, we work diligently and swiftly to address all concerns, including updating and revising policies, disciplining involved employees (including mandatory retraining, suspension and in serious cases, termination) and implementing new protocols with the goal of improving patient care and maintaining consistent compliance with all standards and conditions.
Regarding your questions about the immediate jeopardy designations which were fully remedied over two years ago, these matters primarily related to surveyors’ concerns regarding 1) updating procedures and best practices of our in-hospital pharmacy, 2) demonstrating and updating staff training and proficiency on metal detector screening for contraband, and 3) demonstrating that all requisite staff were properly trained in CPR protocols. These findings were unrelated to any specific, negative patient incident and instead were intended to address the purported need for Cascade to implement improvements to our overall procedures and policies to reduce the likelihood of potential future harm. As it relates to the referenced patient suicide in 2017 (discussed more fully in the following section) our hearts continue to go out to the individuals’ loved ones. Any patient death at our facility, no matter the cause or rarity, is certainly lamentable. Nevertheless, Cascade respectfully refutes as inaccurate any allegation that staff were not properly trained to respond to this unfortunate incident.
Importantly, during follow up survey visits and communications with hospital leaders, DOH regulators specifically recognized and praised Cascade’s efforts to fully address all concerns raised, including “how hard [Cascade] worked” to lift the immediate jeopardy classifications. To reiterate, these isolated matters were the only immediate jeopardy level citations in Cascade’s entire operating history and our leadership and staff responded in an expeditious manner to successfully remediate all concerns.
Cascade’s most recent survey activity occurred during the week of July 23-26, 2019. We were simultaneously surveyed by DOH/CMS and The Joint Commission. Cascade is currently awaiting results from these surveys and it is our good faith belief that no serious level patient safety related findings are likely to be revealed. While Cascade’s consistent goal is zero negative incidents or regulatory deficiencies, it’s important to point out that hospitals of all types (i.e. for-profit, non-profit and government run) routinely encounter similar instances of negative events and alleged regulatory non-compliance matters. As The Times is fully aware; medical/surgical hospitals and psychiatric facilities in the greater Seattle area, Pacific Northwest region and nationally have in recent years been subjected very serious regulatory enforcement including CMS payment terminations, fines, temporary closures, admission suspensions, and similar punitive actions, none of which have ever occurred at Cascade.
Isolated, Negative Patient Incidents & Documentation Discrepancy Allegations:
As noted earlier, Cascade is legally and ethically restricted from providing and confirming specific details involving patient information and treatment encounters. Our hospital places the utmost importance on patient safety and negative event prevention through detection and sustainment actions which are emphasized in ongoing staff training and other clinical quality initiatives. The small number of isolated incidents referenced provide a highly incomplete, inaccurate and non-representative depiction of Cascade that is not at all reflective of the overall quality of care, patient experience and community public health benefit provided by our clinicians to thousands of patients annually.
Cascade’s overall rate of serious level incidents is low given the acuity of our patient population, many of whom have co-morbidities, with such incidents comprising less than 0.008% of all patient treatment days. No hospital, whether BH or medical/surgical, is ever completely immune from isolated, undesirable patient outcomes and regrettable events. All Cascade clinical and support staff are trained and expected at all times to adhere to appropriate documentation and charting practices. Nursing and facility personnel as well as external government and accreditation surveyors routinely review and audit documentation for accuracy and completeness.
We are also mindful that despite the best efforts of our clinicians and staff and overall low serious incident rates, Cascade forthrightly acknowledges that over the course of providing care to 15,000+ patients across 176,000 treatment days over 6 years, regrettable negative incidents do invariably occur that can result in negative and traumatic impacts to the individuals involved and to their loved ones. In these rare situations, we do our best to provide support and compassion to all those affected. It is also never our intention to diminish or trivialize the seriousness of these matters as they represent important opportunities for reflection and evaluation.
We hold ourselves to the highest clinical and ethical standards, and we believe that even one negative incident or outcome is one too many. When these uncommon situations arise, we do our best to identify lessons learned and where appropriate, we make changes to our protocols while holding all individuals fully accountable for their actions including those that may deviate from their training and our policies. We consistently strive to reduce and eliminate negative occurrences to all patients entrusted to our care as well as our valued staff members. We also strongly emphasize the critical importance of placing such atypical events in the appropriate context as non-representative, temporary departures from the overall high level of quality clinical care experienced by the overwhelming majority of Cascade’s patients which do not equate to systemic or chronic issues.
As it relates to your questions surrounding rounding and charting practices following the 2017 patient suicide, this was absolutely not a situation involving any bad faith or attempt to “cover up” a death. Rather, one of Cascade’s Certified Nurse Assistants failed to follow established hospital procedures in what was a wholly unfamiliar, unprecedented and traumatic event where she continued to round without knowing the precise procedures for notating such events. Immediately following the incident, the staff member was offered support and underwent mandatory retraining regarding proper charting and documentary protocols. Consistent, accurate, comprehensive documentation is an issue all hospitals continuously work to improve, and Cascade is no exception.
Cascade maintains robust policies and procedures designed to keep our patients safe from potential self-harm and suicide, including state of the art anti-ligature fixtures, required 15-minute checks performed 24 hours a day and specific training for our staff to recognize warning signs of a patient in need of additional precautions. However, and despite our best efforts in very rare instances, a patient suffering from severe illness will find a way to end his or her life during treatment at a hospital. In fact, inpatient suicide often ranks among the top Sentinel Events reported to The Joint Commission from hospitals across the country. To be clear, this was the only patient suicide in the entire history of Cascade, and we hope and pray it is the last.
The safety of all of our patients and staff members is of tantamount importance and a responsibility we take very seriously, particularly in light of the high acuity patient population that can occasionally exhibit aggressive behavior. Like many hospitals treating similar patient populations, we constantly evaluate our policies, procedures and capital improvement strategy (including in seen and unseen safety/security technologies) in an effort to reduce such incidents with the aspirational goal of zero negative incidents, including assaults and injuries to patients and staff.
All claims of workplace injury to staff are fully investigated and processed in accordance with internal hospital protocols and applicable federal and state laws governing workers compensation. Notwithstanding that Cascade has treated tens of thousands of high acuity patients while employing roughly 800 staff members since 2014, these types claims are relatively uncommon, totaling just 0.027% per patient treatment day.
As noted earlier, Cascade maintains strict policies requiring that all applicable adverse incidents be reported in full accordance with WA State guidelines. Our staff are trained to identify events meeting criteria for reporting and our consistent goal and expectation is 100% compliance. It is also important to clarify that not all incidents (including ones that could reasonably be deemed undesirable) necessarily meet the formal legal criteria for classification as adverse based on the state guidelines. Nevertheless, it is Cascade’s policy to err on the side of reporting and disclosure of such incidents, both internally for evaluation and performance improvement purposes and to meet our state reporting requirements. Cascade strongly disputes and rejects any inference that our staff improperly or purposefully misclassifies or omits required adverse incidents from any state mandated reports.
Law Enforcement Dispatch/City of Tukwila Nuisance Classifications:
In general, law enforcement dispatch to Cascade (particularly for 911 calls) is not a common practice. This is in large part due to our staff’s specialized training (including in advanced de-escalation and therapeutic restraint techniques) which better equips them to deal with the unique medical needs of psychiatric patients.
The definition of a “chronic nuisance property” is covered in Tukwila municipal code. If a residence or business has 3 or more police calls in 90 days or 7 or more in 12 months, it is automatically placed on their designated list. Nuisances generally refers to such incidents as drug related activity, assault, reckless endangerment, stalking or harassment, disorderly conduct, prostitution, failure to disperse, weapons violations, gang related activity.
It is Cascade’s view that as a psychiatric hospital providing critically needed community-based health services to many vulnerable patients, we do not appropriately fit the criteria, classifications or incidents that this code was intended to address, and we have repeatedly stated this position to city and police officials. However, like nearly all hospitals (particularly ones treating patients whose illnesses can manifest in aggressive and assaultive episodes), we do occasionally experience situations necessitating law enforcement support. Moreover, state and federal law and regulations require notification and referral to police for particular types of matters including alleged abuse, serious property damage and theft.
Nevertheless, we continue to work collaboratively with the City and Tukwila Police Department to reduce the overall number of calls from our facility and keep us from being included on this list. Our hospital always cooperates fully with local law enforcement and values their support and service to our community.
Resolution of legal claims / Settlements Do Not Equate to Admission of Liability:
Reliable health care industry benchmarking studies conducted within the past several years confirm that there are approximately 35,000 annual litigation claims filed against hospitals in the U.S. Lawsuits by patients and their families are uncommon at Cascade but similar to the vast majority hospitals, they do occasionally occur, including allegations that resolved for de minimis or nuisance values usually far below the cost of defense.
As a general matter, such settlements (including confidential ones) do not constitute admissions nor findings of liability or wrongdoing in any particular matter but rather reflect the high costs (both financial and time), the overall uncertainties and unpredictable nature of our judicial system and a desire to remain singularly focused on the core mission of providing high quality care to patients and their families.
On behalf of the entire Cascade team, we sincerely hope this information will assist in your efforts to produce a balanced, fact-based portrayal of WA’s mental health treatment system, our hospital’s role in providing care to our valued patients and the dedicated efforts of our clinicians and support staff that I have the privilege to lead.
Doing anything less would be unfortunate, just not for Cascade and similar providers but more importantly, in light of the ongoing and serious need to proactively confront the historical stigmas, shame and societal misconceptions that too often surround mental health disorders and patients. I’d therefore respectfully encourage you be sensitive in portraying these complex matters and do so in manner that diminishes the possibility of the reportage being unwittingly misconstrued and sensationalized thereby perpetuating fear inducing stereotypes that could dissuade vulnerable individuals from seeking life-saving inpatient psychiatric care for themselves or their loved ones.
Cascade will continue to focus on our core mission of providing critically needed, high quality, compassionate and specialized care to our valued patients and their families across our community. We look forward to a continued collaborative relationship with you and the Seattle Times.