The Colorado State Veterans Home at Fitzsimons: A Long Term Mismanaged Administrative Disaster: Part Two: “The Hot Mess” and Fitz’s Health Inspection “Tags”

“The great (those in power) commit almost as many shameful acts as the outcasts of society, but they commit them in the dark, and make a parade of their virtues- and so they remain great! The little men hide their virtues, and expose their miseries for all to see – and so they are despised.”

Balzac – Lost Illusions.

Oversight.

Although other departments of the Colorado Department of Human Services (DHS) have gotten media attention as a result of system-wide mismanagement, for the most part, the Colorado Veterans Community Living Center at Fitzsimons (CVCLC), nicknamed “Fitz”, has not, or hardly. Curious. Curious because over the last several years the place has been mired troubles. These have included chronic employee and management turn over; employees placed on administrative leave on questionable if not fictitious grounds; a system of administrative spying on employees and residents; an attempt “to purge” at least one resident critical of how the facility was run; and what many employees described as “an atmosphere of fear” (and some still do) despite recent improvements.

How and why it was all done remains a murky process in a state-run institution that should be open to public scrutiny.

There was also a concerted attempt to destroy the union at the facility, a branch of the state employees union, Colorado WINS. This union-busting campaign was engineered by since-fired Human Services Administrator, Vicky Manley and her hand-picked administrative pit bull, Debbie Blanc (also relieved of her duties at DHS). This campaign was initiated despite the fact that the union and the state government have, overall, a good cooperative relationship in an “employee-management cooperation” in the facility.

The unacknowledged crisis at Fitz was only a part of a larger mismanagement mess facing the multi-billion dollar-funded DHS, headed by Executive Director, Reggie Bicha, who has been appointed and supported by the state’s governor, John Hickenlooper. Both of them were repeatedly – and from different sources – made aware of the situation. Neither the governor’s office, the legislature, the media nor the brain-dead state veterans nursing home advisory board showed any interest in or lifted a finger to address to address the crisis until the more generalized crisis within DHS broke in the Denver Post.

Then in May of this year, 2016 that changed after the media focused on a particular incident. Residents at a state facility, the Pueblo Regional Center were strip-searched on an order that came down from on high at Colorado Division of Human Services, thus violating privacy of more than 60 residents. As detailed from a suit filed on behalf of the residents whose rights were violated:

These nonconsensual searches were conducted at the behest of (at least) Division
Director for Regional Center Operations Defendant Tracy Myszak (who was present at PRC during the searches), Defendant Myszak’s supervisor, Defendant Viki Manley (CDHS Director of Community Access and Independence), her Deputy Director, Defendant Sarah Aurich, Defendant Nikki Hatch (Deputy Executive Director of Operations), and CDHS Executive Director, Defendant Reggie Bicha (collectively referred to at times as “supervisory Defendants”). All these Defendants personally participated in the searches and thereby caused them to happen by directly ordering the searches, ratifying the searches ahead of time despite being fully aware of the purported factual bases (and thus lack of legal support) for them, and/or promulgating deficient policies.

Put another way high level administrators at Colorado Department of Human Services, including its Executive Director, Reggie Bicha initiated and the conducted a strip search of more than 60 residents, many of who are either mentally or physically incapacitated. As the suit noted at the outset:

On or about March 25, 2015, Division Director for Regional Center Operations
Defendant Tracy Myszak directed nearly a dozen of her subordinate Defendants at CDHS to storm into the Pueblo Regional Center without notice and conduct warrantless, nonconsensual strip searches of most or all of the residents, including hands-on genital contact in many cases

One of these residents is related to a Colorado state legislator who organized a letter of no confidence in DHS’s Executive Director, Reggie Bicha originally signed by 89 Colorado legislators. It was sent to Governor John Hickenlooper and leaked to the press, exposing the tip of the iceberg. Even then, the problems at the Fitz facility was hardly mentioned.

Yet nothing was done, despite the fact that both the media, legislature and the brain-dead state veterans nursing home advisory board all knew in a general way – and many of the specifics – the extent of the crisis.

All this had to have consequences on resident care and employee morale.

“The Jewel in the Crown”

CVCLC is one of a number of state-run veterans homes managed by the Colorado Division of Human Services and funded by the Colorado legislature as well as the federal government through Medicare and Medicaid. The facility first opened its doors in 2002; it was built to show the states’ concern for veterans living in Colorado. Always envisioned to be a model institutions, Fitz was boasted to be “the crown jewel” in the DHS nursing home system. But the Fitz” facility was special. But within a year of its opening “the crown jewel” experienced high infection rates, rampant theft (tv’s in particular seemed to disappear) and half a wing was empty. At one point some ten years ago, the facility was in such poor condition that it was prohibited from accepting new residents, a situation which was addressed at the time. A former HS employee noted, “Americans don’t put up with second class sub-par service for veterans, even though that is not what is budgeted for.”

Fitz was boasted to be “the crown jewel” in the DHS nursing home system. Unfortunately, it has been plagued with problems from the outset.At one point some ten years ago, the facility was in such poor condition that it was prohibited from accepting new residents, a situation which was addressed at the time.

Empty wings translates into less federal funding. The director of the department heading up the facility, Vicky Manley, was told to “clean up the hot mess”, a task that subsequent events would suggest she was, to an astonishing degree, poorly equipped to handle .” DHS also hired a management consulting firm, Pinõn, to help with the process. A few years ago, Pinõn changed its name to Vivage.

Crisis Quieted Down But Not Over

Although the situation at the facility has improved some and quieted down considerably, the scars of what was for many a harrowing few years are not that far from the surface, structural problems still exist. The last time that Colorado’s Department of Public Health and Environment (CDPHE) completed an inspection of the CVCLC was on May 11, 2016. The inspectors did find some deficiencies but none of them rated above a minimal level of harm or potential of harm. The criticisms therein did include:

• the failure to investigate the hiring of an employee to insure “no legal history of abusing, neglecting or mistreating residents;” in the same complaint, a failure to “report and investigate any acts or reports of abuse, neglect or mistreatment of residents”. The particular case involved a resident with “severe cognitive impairment and behavior symptoms directed towards others” who had “behavior aggression” and “had pinched people.”
• the case of five CNAs (Certified Nursing Assistant) hired without proper licenses b. the institution was also tagged for failing to adequately train new hirees on prevention, neglect and mistreatment. The Director of Nurses at the time (since replaced) replied to the charge that it was not her responsibility to double-checks licensing but that of the Human Resources division.
• An LPN’s unsafe use of an insulin syringe

Note that in the above cases, and several others in the report, that the “level of harm” described was minimal and that the residents affected were few. CDPHE maintains an inspection system in which “deficiencies” are rated on an alphabetical scale from A through L, those deficiencies rated closer to “A” (A,B,C) are considered minor, so much so that they do not result in fine. On the other hand, “J,” “K” or “L” level deficiencies are considered very serious. In its May, 2016 inspection, all of the deficiencies were tagged in the “F” category, not serious enough to warrant “Fitz” (as the Colorado State Veterans Home at Fitzsimmons is referred to) being fined, but still serious enough to require “corrective action” and a follow-up inspection.

If not for the state and federal agency oversight and inspection, it is chilling to think how more poorly run and abusive the nursing home industry would be. Any nursing home – state or corporate run – that takes money from Medicare and Medicaid must be inspected every nine to fifteen months. CDPHE sends in a team of four to six people; they are at the facility for four to six days: they talk to patients, they read records and then they follow a procedure to determine deficiencies; anytime the inspectors find something that doesn’t meet their criteria, a facility gets“tagged”.

To the dismay of Colorado nursing home administrators, but to the emotional security and health of the institutions’ residents and family members, CDPHE is known to be one of the more aggressive and “tag friendly” institutions. The inspection policies and practices of CDPHE are certainly something all Coloradans can be proud of. More than likely less careful inspections would only lead to more problems, cover ups, etc.

Vivage and “Fitz”

Nor is it only state institutions that are inspected, but private ones as well, among them, those run by the healthcare consulting firm Vivage. Until recently, Vivage not only provided temporary administrators  but it also had consulting contracts with the states’ DHS’s nursing home system. It also runs a series of eight of its own nursing homes throughout the state that have had the misfortune of getting frequently “tagged” by Health Department inspectors, much to the annoyance of Vivage’s CEO, Jay Moskowitz, a friend of Governor John Hickenlooper. Moskowitz is also the first vice chair of the Colorado Healthcare Association and Center for Assisted Living, the state’s main private nursing home lobbying firm.

Since the May, 2016 inspection the Official U.S. Government Site for Medicare has reported a number of other deficiencies at “Fitz” which include 4 health deficiencies, 2 mistreatment cases, 1 quality care deficiency, 1 problem with the pharmacy service, 8 fire safety deficiencies, 3 automatic sprinkler system problems and one problem with the electrical system. These issues will more than likely all be investigated and addressed in the next state inspection.

These results are not all that bad, when compared with national averages, comparisons that while having certain limits (what if the whole system is below standard?), are interesting. If Fitz’s fire safety deficiencies are well above national averages, the institution’s health inspection deficiency tags are below national averages for problems with one notable exception: In 2013 the Fitz facility got a “double K” tag for which it was fined. One element of the tag because of coumadin distributions  not being properly communicated and administered. Coumadin is classified as a high risk medication because it has blood thinning properties.

In 2013 the Fitz facility got a “double K” tag for which it was fined. One element of the tag because of coumadin distributions  not being properly communicated and administered. Coumadin is classified as a high risk medication because it has blood thinning properties..

The cause of the problem was traced to a new facility computer software program developed by ADL.

ADL Data System and the “Double K” Tags

All indications are that the source of the coumadin problem stemmed from a new software management program developed by a long existing company, ADL Data Systems, a Hawthorne, New York software company. The software provided was meant to manage the use of prescription medicines at the Fitz facility  but it had some serious glitches. ADL is one of the nation’s leading companies producing software for nursing homes, yet the contract between the software company and Colorado Human Services left much to be desired. The cost and the nature of the contract between DHS and ADL remains unclear. There are claims that ADL never did a test run of the software, that the ADL staff only gave inadequate computer training to the nurses and CNAs. It was alleged that ADL would write-up instructions to help clean up the problems but that these instructions were not properly communicated to the nurses. After the double K tag was given, the ADL software system was removed and a prior software system put back in place.

The other part of the “double K” tag fine was against the facility administrator for not fixing what DHS referred to as “the hot mess” at Fitz. It is difficult for any administrator to survive a Level K fine, and Fitz administrator at the time, Brad Honl, was soon released from his responsibilities. There are indications that Honl was well aware of the institutions problems and had repeatedly communicated them  “up the line”  to Human Services’ director at the time Vicky Manley.  Honl, who went on to work elsewhere in the private sector state nursing home world, got no cooperation and took the fall for the mess. Later, Manley herself would get the axe from Human Services.

One final note, there is a curious consequence to the last Fitz inspection. On a comparative basis, the deficiencies detailed were not too serious,  still, “Medicare.gov,” the Official U.S. Government Site for Medicare gives the Fitz facility an overall rating of only “2 out of 5 stars” in its most recent evaluation; this rating is defined as “below average.” Furthermore although Medicare.gov rates Fitz’s staffing as “above average” an impressive 4 out 5 on its scale, its “Quality Measures” are a lousy “1” and its “Healthcare Measures” at a measly “2”, suggesting systemic problems continue to fester. Quality measure include, among other indicators, such things as the number of resident falls, urinary track infections, unacceptable pain levels.

So…a better than average inspection conclusion results in a lower than average rating by a national government rating agency? Suggests that there is more to the story, more problems below the surface. But that is the subject of another article.

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Related Links

The Colorado State Veterans Home at Fitzsimons: A Ten Year Mismanaged, Administrative Disaster. Part One: The Guv. December 28, 2013

Hickenlooper’s Burden: The Ten Year Mess at the Colorado Department of Human Services. August 11, 2015