Ventura County Grand Jury • 2018-2019 • Agency Response
Response to: Pesticide Monitoring Near Schools and Day-Care Centers

Respondents

Published: May 02, 2019 9 pages
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Findings and Recommendations 7 findings

F01
The Aegis and Western Pacific clinics are contractually required to provide detailed reports of services provided and outcome data to VCBH. However, VCBH does not make any of this information available to the general public. VCBH Response: Disagree Partially While Ventura County Behavioral Health does not have a public-facing website that provides o specific data regarding outcomes, it is part of the Department’s strategic plan for 2019-2020 to develop and implement such a site. Ventura County Behavioral Health Alcohol and Drug Programs Division (VCBH-ADP) does make outcome data public each year when contracts are approved by the Board of Supervisors (BOS). For example, in the June 18th BOS board letter, the following data was made available to the public regarding services outcome data: Pa g e | 1 Ventura County-Contracted Narcotic Treatment Programs Ventura County 2018 – 2019 Grand Jury Final Report Joint Response from Ventura County Board of Supervisors & Behavioral Health “In FY 2017-18 Aegis served approximately 874 D/MC clients. Since July 1, 2018, Aegis has served 894 D/MC clients and anticipates serving 930 D/MC clients by the end of this fiscal year.” “For FY 2017-18 Western Pacific served 564 D/MC clients. Since July 1, 2018, Western Pacific has served 569 D/MC clients and anticipates 580 D/MC clients by the end of this fiscal year.” In addition, Aegis Treatment Centers and Western Pacific Med Corp make requests for data o on program effectiveness available through their websites, and representatives from Aegis and VCBH have presented data outcomes at multiple Behavioral Health Advisory Board (BHAB) General and BHAB Prevention meetings, which are both open to the public.
Related Recommendations (1)
R01
The current VCBH contracts require one site visit per year by VCBH staff. The Grand Jury recommends more unscheduled visits and documentation of those visits upon completion. (C-03) VCBH Response: This recommendation has been partially implemented. The County currently conducts unscheduled visits and will begin documenting the process o within the next six months.
F02
For the past several years VCBH has contracted with Aegis and Western Pacific to provide narcotic treatment and counseling services in the County. The contract requires VCBH to “…conduct at minimum an annual review of the facility, policies, and documentation of compliance, conduct a survey of clients and staff, tour the grounds, and address any concerns or issues found.” VCBH Response: Agree
Related Recommendations (1)
R02
The Grand Jury recommends that VCBH fulfill its contractual obligation in oversight of each clinic. (C-03, C-04) VCBH Response: This recommendation will not be implemented. It is not warranted or reasonable. VCBH fulfills contractual oversight obligations for all clinics. See FA-03, C-03 and C-04 for o specifics.
F03
An internal audit by VCBH conducted of Aegis and Western Pacific records from February 4, 2013, through August 22, 2018, showed consistent problems with documentation. Most notably, at one of the clinics, more than half of 100 reviewed files revealed that methadone dosage was not charted as required. VCBH Response: Disagree Wholly Narcotics Treatment Program (NTP) services are State Medi-Cal/Federal Medicaid o entitlement benefits for the treatment of Opioid Use Disorder (OUD) the County is required to offer, and VCBH monitors clinics more often than the Intergovernmental Agreement with the Department of Health Care Services (DHCS) requires. VCBH inspects/audits clinics monthly, whereas other counties only inspect/audit annually. VCBH does not “defer a significant part of the oversight to state and federal agencies” as stated in the 2019 Grand Jury report summary. In fact, from February 4, 2013 to August 22, 2018, VCBH staff completed 27 annual site visits, 386 Utilization Review (UR) monitoring visits and reviewed 4,376 client files. Per the Intergovernmental Agreement with the California Department Health Care Services (DHCS), VCBH is required to make one annual site monitoring visit per year. If there were “consistent problems with documentation,” Western Pacific Med Corp and/or Aegis Treatment Centers’ clinics would have been stripped of their licenses and shut down long ago by State and Federal regulators. In addition to VCBH’s rigorous oversight, NTP clinics are licensed and strictly monitored by o DHCS, the Department of Justice, Drug Enforcement Administration (DEA), and the federal Substance Abuse and Mental Health Services Administration (SAMHSA). In fact, the NTP Pa g e | 2 Ventura County-Contracted Narcotic Treatment Programs Ventura County 2018 – 2019 Grand Jury Final Report Joint Response from Ventura County Board of Supervisors & Behavioral Health modality is the most heavily regulated level of Substance Use Disorder (SUD) treatment in the United States. Because NTPs use electronic medical records, it is impossible for methadone to be dispensed o without the dosage being charted. NTP providers use automated dispensing equipment in conjunction with computer software programs. As outlined in the U.S. Department of Justice Narcotic Treatment Programs Best Practice Guidelines (https://www.deadiversion.usdoj.gov/pubs/manuals/narcotic/part4/index.html) medication variances are impacted by manufacturing processes and dispensing pumps and scales calibration. When a patient arrives, they register with the receptionist, who electronically notifies the dispensing nurse. The nurse then doses the patient. This is the only way the nurse knows which patient is coming to the window next. The transaction cannot be handled without the dose being logged in the patient’s electronic chart and appearing on the computer screen. The information on dosing from the DEA and the above explanation was provided to the Grand Jury on March 11, 2019.
No recommendations for this finding
F04
The Aegis website states that “80% of our patients are drug free within 90 days.” It also states that “88% of our patients stop using illicit opioids within 90 days.” These two statements are conflicting. They are also incompatible with VCBH’s stated aim, which is not to cure, but to “treat” or stabilize NTP patients so they can be healthy and productive members of society. VCBH Response: Disagree Wholly The two statements, “80% of our patients are drug free within 90 days” and “88% of our o patients stop using illicit opioids within 90 days,” are not mutually exclusive. The conflict arises from the Grand Jury’s misguided belief that the use of medications to treat opioid use disorder does not constitute living as “drug-free.” Also, there is a major difference in the two statements: the word “illicit.” Illicit implies illegal drugs, whereas “drug-free” is a general description that includes any drugs of any kind. For example, many prescription drugs are prescribed to patients by doctors. Those are legal and not illicit; however, prescription drugs that are sold illegally and not prescribed to the recipient are considered illicit drugs. “Street drugs” such as heroin, methamphetamines and cocaine are also considered illicit drugs. The Grand Jury also grossly misinterprets what it means to be free of illicit drug use and o misinterprets VCBH’s aim to treat and stabilize. See the treatment section of Ventura County Responds: https://venturacountyresponds.org/en/what-is-the-opioid-crisis: “The Opioid (Narcotic) Treatment program provides daily or several times weekly medication and counseling available to maintain stability for those with an opioid use disorder. Studies show that people with an opioid use disorder who follow detoxification with complete abstinence are very likely to relapse, or return to using the drug. While relapse is a normal step on the path to recovery, it can also be life threatening, raising the risk for a fatal overdose. An important way to support recovery from heroin or prescription opioid use disorder is to maintain abstinence from those drugs. Someone in recovery can also use medications that reduce the negative effects of withdrawal and cravings without producing the euphoria that the original drug of abuse caused. (Source: NIDA. (2018, June 8). Medications to Treat Opioid Use Disorder”) Pa g e | 3 Ventura County-Contracted Narcotic Treatment Programs Ventura County 2018 – 2019 Grand Jury Final Report Joint Response from Ventura County Board of Supervisors & Behavioral Health
Related Recommendations (1)
R04
The Grand Jury recommends that VCBH adhere to all federal, State and County contractual policies and procedures in order to ensure continued funding for the administration of narcotic treatment programs. (C-04) VCBH Response: The recommendation will not be implemented. It is not warranted or reasonable. Since VCBH adheres to all Federal, State and County contractual policies and procedures, o the Department is not at any risk of losing government funding. In addition, NTP services are State Medi-Cal/Federal Medicaid entitlement benefits for the treatment of Opioid Use Disorder (OUD) the County is required to offer. The Department’s objection to this recommendation is outlined in FA-03 and C-04. Pa g e | 6 Ventura County-Contracted Narcotic Treatment Programs Ventura County 2018 – 2019 Grand Jury Final Report Joint Response from Ventura County Board of Supervisors & Behavioral Health
F05
A Harvard School of Medicine expert, among other researchers, has drawn parallels between “opioid use disorder” and type 2 diabetes, i.e., both requiring lifelong management. VCBH Response: Agree
Related Recommendations (1)
R05
The Grand Jury recommends that VCBH improve its existing educational materials regarding the goals and reasonable expectations of MAT programs. (C-01, C-02) VCBH Response: The recommendation will not be implemented because sufficient information exists. Materials and information regarding MAT expectations are available on two public websites o and public brochures: The Ventura County Limits website states an “Opioid (Narcotic) Treatment program provides daily or several times weekly opioid agonist medication and counseling available to maintain stability for those with opioid use disorder; Medication Assisted Treatment provides ordering, prescribing, administering and monitoring of medications for substance use disorders.” (http://www.venturacountylimits.org/en/treatment/adult-services) Pages 18-19 of The Opioid Crisis: Ventura County Responds booklet contains an abundance of information regarding reasonable expectations of MAT. This booklet can be downloaded online at https://venturacountyresponds.org/en/what-is-the-opioid-crisis which is a website dedicated to Ventura County’s response to the Opioid Crisis and includes information on treatment services.
F06
The Grand Jury interviewed law-enforcement and city-government officials. It was learned that incidents involving people loitering, trespassing, passing out, and drug dealing occurred in the immediate vicinity of some of the clinics. VCBH acknowledged that illicit drug use might occur outside some clinics but had no knowledge of any of these incidents involving clinic patients. VCBH stated that of the five NTP clinics, only the Aegis clinic in Oxnard maintains security personnel on site. VCBH Response: Disagree Wholly VCBH has received no reports from law enforcement or city government of incidents involving o clinic clients specifically. In May of 2018, Alcohol and Drug Programs Division Chief, Dr. Loretta Denering, received a call of concern from the Ventura City Council stating the homeless population might be traced to the patient population. Dr. Denering contacted the CEO of Western Pacific, Mark Hickman, immediately, who responded to the City Council and invited them to the clinic (after hours). Mr. Hickman’s staff educated the City Council and representatives on Medicated Assisted Treatment programs. All the City Council’s questions were answered, and they left with a very favorable opinion of the clinic. During this meeting, the broader challenges the entire city is facing in terms of the growing homeless population were discussed. Western Pacific Med Corp clinic incurs the same issues with this population as any other business in the City of Ventura, and there are several motels in the vicinity that offer transitional housing for the homeless. On occasion, “loitering, trespassing, passing out, and drug dealing” were observed near these facilities, but Western Pacific Med Corp clinic has a close working relationship with local law enforcement, including the City of Ventura Police Department. The Ventura Police Department has always been willing to work with Western Pacific to ensure transients do not bother patients or neighbors. Contrary to the statement in the report that only Aegis maintains security at its Oxnard clinic, the Western Pacific Med Corp clinic employs a full-time security guard. All five NTP clinics have cameras outside and inside. In addition, Aegis employs security guards and clinic concierges at two of its three Ventura County facilities. Concierges assist with patient traffic and customer service within the treatment facility and intentionally do not dress in a security uniform because it’s proved to be the most effective and appropriate means of patient traffic control and customer service.
Related Recommendations (1)
R06
The Grand Jury recommends that VCBH provide performance outcome data to the public on its contracted MAT programs. (C-01, C-02) VCBH Response: This recommendation has been partially implemented. As stated in FA-01, VCBH has included the development of a public-facing website that o provides outcome specific data as part of the Department’s strategic plan for 2019-2020. In addition, Aegis Treatment Centers and Western Pacific Med Corp make requests for data on program effectiveness available through their websites. Further, representatives from Aegis Treatment Centers and VCBH have presented data outcomes at multiple Behavioral Health Advisory Board (BHAB) General and BHAB Prevention meetings, which are both open to the public.
F07
VCBH staff said they conducted unannounced site visits in 2018-2019 but did not document them. VCBH Response: Agree Pa g e | 4 Ventura County-Contracted Narcotic Treatment Programs Ventura County 2018 – 2019 Grand Jury Final Report Joint Response from Ventura County Board of Supervisors & Behavioral Health CONCLUSIONS: C-01: The Grand Jury concluded that opioid addiction could result in a lifelong MAT regimen. Aegis marketing materials and VCBH’s stated aim are confusing with regard to the effectiveness of MAT and the cure rate for opioid-addicted patients. (FA-04, FA-05) VCBH Response: Disagree Wholly There is a misconception held by the Grand Jury that if a patient is able to abstain from the o abuse of drugs (illicit or not), they are “cured.” This is not a position held by Federal authorities (SAMHSA) and Centers for Medicaid and Medicare (CMS), State and local authorities (DHCS and HCA/VCBH) or the substance use disorder treatment, medical, and scientific communities. There is no cure rate for individuals with Opioid Use Disorders, and Aegis’ marketing materials do not make any claims regarding a cure rate for opioid addition. Also, VCBH’s stated aim is to treat or stabilize NTP patients so they can be healthy and productive members of society, not cure them. Recovery is a long process, and the ability of a patient to cease undertaking harmful activities like consuming drugs is merely one step in a lengthy process. C-02: The Grand Jury concluded that VCBH does not provide any data to the public on measurable outcomes of the NTPs in the County. (FA-01) VCBH Response: Disagree Partially As stated in FA-01, VCBH intends to develop a public-facing website with data outcomes in o the next fiscal year but currently provides data for treatment programs in BOS Board Letters and through public presentations. C-03: The Grand Jury concluded that VCBH does not conduct sufficient unannounced site visits and facility inspections. When conducted, site visits were not documented. (FA-02, FA-07) VCBH Response: Disagree Wholly As previously indicated in FA-03, all required regulatory site visits are performed annually for o Ventura County’s contracted Narcotic Treatment Providers. Site visit dates for FY 17/18 were performed in the month of June 2018. In addition, the word “sufficient” is an implied bias on the part of the Grand Jury since VCBH completes the required annual site visits and conducts unannounced site visits when there is cause to do so. C-04: The Grand Jury concluded there is lack of oversight by VCBH regarding adequate documentation by NTP clinics in Ventura County. This could put at risk future government funding. (FA-03) VCBH Response: Disagree Wholly As previously indicated in FA-03 and CA-03, all required regulatory site visits are performed o annually for Ventura County’s contracted Narcotic Treatment Provider clinics. Future funding Pa g e | 5 Ventura County-Contracted Narcotic Treatment Programs Ventura County 2018 – 2019 Grand Jury Final Report Joint Response from Ventura County Board of Supervisors & Behavioral Health is not at risk because the Department complies with requirements in the Intergovernmental
Related Recommendations (1)
R07
The Grand Jury recommends that VCBH enhance security at contracted NTP clinics. (C- 05) VCBH Response: This recommendation will not be implemented. It is not warranted or reasonable. See VCBH’s objection to this recommendation in C-05 and FA-06. o Pa g e | 7

Conclusions 2