Mental Health Crisis Team and Behavioral Health Management

In 1996 there were 20 full-time Team members. Teams were available 24 hours a day on 12-hour shifts. The teams would respond to community requests for assistance and they would be called by police when mentally ill persons were encountered.

Since July 1, 2004, the Team has been funded for 10 staff members. They no longer evaluate people in their homes or respond to the police when assistance is requested.

2 The Ventura County Behavioral Health Intranet web site address is http://vcweb/hca/vcbh This address is internal to Ventura County government and is not publicly accessible from the Internet. Ibid. Mental Health Crisis Team and Behavioral Health Management 3 Proc. Effective # Policy Name Date CT1 Domestic Violence Screening 04/16/01 CT2 Screening and Treatment Decision Protocol for Patients Presenting to Hillmont Psychiatric Care 09/24/01 Center Crisis CT3 Transportation of Clients 01/16/02 CT4 Crisis Team Admission Concerns 07/31/98 CT5 Referrals – Crisis Team 01/18/93 CT6 Patient Alert Forms 07/31/98 CT7 Crisis Team – Off Site Services and Physician 07/99 Oversight CT8 Crisis Team – Attending Physician 12/01/01 CT9 Crisis Team – Progress Note 07/99 CT10 Crisis Team Assessment 02/18/93 CT11 Crisis Team – Brief Services Assessment 01/18/93 CT12 Crisis Team Records Assembly 01/16/02 CT49 Client Personal Property Inventory and Search 11/19/03 Table 1. Crisis Team Policies and Procedures as of March 26, 2005 Proc. Effective # Policy Name Date CT3 Transportation Arranged by Crisis Team 12/12/03 CT5 Referrals – Crisis Team 12/12/03 CT6 Patient Alert Forms 12/12/03 CT11 Crisis Team – Brief Services Assessment 12/12/03 CT13 VCBH Crisis Team Telephone Triage 12/12/03 CT17 Initiating a Welfare and Institutions Code Section 12/12/03 5150 Application CT23 Crisis Team HIPPA Standards 12/12/03 CT26 Crisis Telephone Management – Staff Shortage 12/12/03 CT27 Crisis Team Procedure for Using Greyhound Bus 12/12/03 Ticket Purchase Authorization CT30 Crisis Team Dispatch Tracking of Mobile Teams 12/12/03 CT32 Crisis Team Charting and Billing 12/12/03 CT33 Log Book Documentation 12/12/03 CT44 Maintenance of Crisis Team Vans 12/12/03 CT48 Medical Necessity Taking Precedence Over W&I Code 5150 Upon Admission to Non-LPS Designated 12/12/03 Facility Table 2. Crisis Team Policies and Procedures as of April 19, 2005 F-19. The documents provided by the Director of BHD did correspond to new Team duties; however, these documents were not on the Intranet and accessible to the employees until April of 2005, nearly 16 months after the recorded effective date of every document. Mental Health Crisis Team and Behavioral Health Management F-20. Neither the Team members nor their supervisors had been informed that procedures were being reviewed or that new P&P documents had been placed on the Intranet in April of 2005. There was no email received by any staff announcing these policy changes. F-21. For instance, the procedure CT1, titled “Domestic Violence Screening,” is a function that Team members believe they are required to perform. However, that function has been removed from the Intranet web site by the Director of BHD without informing the Team staff. F-22. The new P&P documents were back-dated to appear that they had been on the Intranet since at least July 2004, coincident with the downsizing of the Team. F-23. The documents showed inconsistencies and the explanations introduced additional inconsistencies. F-24. Recovered backup files from the Intranet server, provided by ISD, confirmed that the documents now on the Intranet, showing Effective Dates of 12/12/03 and Revision/Review Date of 07/01/04, were actually created by the MA around April 19, 2005. F-25. Multiple backups from ISD were analyzed and there was a consistency in the older version of policies and procedures between December 2003 and April

The Team has a working supervisor. Three levels of supervision currently exist between the Team and the BHD; however, two of those supervisors have little knowledge of, or involvement with, the Team.

Crisis Team staff demonstrate a high degree of responsibility to the clients within the community.

In planning the Team’s downsizing, management had a responsibility to adhere to budgets and cost controls to the detriment of provided services.

The Code of Conduct for the Ventura County Medical Center states, “Employees and agents deserve clear instructions about what is expected of them.“1 Well-documented and well-maintained procedures help a hospital or health care agency avoid problems such as misidentification of patients, wrong-site surgeries, improper billing, caregiver and medication mix-ups, etc.

The Code of Conduct further states, “Employees and agents shall promptly report all suspected violations of the Code of Conduct, Compliance Guidelines, operational policies, laws, or regulations to their manager or supervisor, through the Confidential Compliance Line or to the Compliance Officer.”

The Department requires that all Policies and Procedures (P&P) be maintained on the Intranet so they will be accessible by all employees at all times. Code of Conduct No. 1, “Ventura County Medical Center Code of Conduct & Confidential Disclosure Program” 2 Mental Health Crisis Team and Behavioral Health Management

Hardcopy (paper) P&Ps have not been distributed to staff in the past two to three years, since at least June of 2002. If staff members require hardcopies of P&P documents, they must print their own from the Intranet website.2

There was a hardcopy P&P notebook available to the Team at one time, estimates ranging from two to four years ago. There has been no official hardcopy P&P notebook available to Team staff since before March 2004.

There is an approved P&P, identified as procedure number “A1” (Procedure A1, see Attachment 1) describing the single, integrated master P&P manual. Procedure A1, located on the department Intranet, states that the Behavioral Health Director is “responsible for coordinating development and implementation of policies and procedures.”3 It also explains the function of the Policy and Procedure Committee, the use of an “approvals sheet” to record approvals, and the dissemination of a memo and training information.

Currently, Procedure A1 is outdated and in need of revision. There is no “approvals sheet” or Policy and Procedure Committee.

A Management Assistant (MA) is responsible for coordinating changes to P&Ps throughout the department, performing this function since October of 2004 and revising over 50 of the department’s P&Ps to date. A P&P is considered in effect at the moment the MA places it on the Intranet.

When a new or revised P&P document is placed on the Intranet, an authorized copy is signed by the BHD’s Director and the Medical Director. The signed paper copy is then placed in the master manual (notebooks) stored at the MA’s desk.

When a new or revised P&P document is placed on the Intranet, it is the MA’s responsibility to send an email to supervisors and staff to inform them that an update has taken place. Crisis Team Policies and Procedures

Team duties reportedly changed twice in 2004. One change was a result of reorganization in March of 2004. The second change was the result of downsizing the Team in July 2004.

A review of an ISD web site backup of March 26, 2005, showed that P&P documents on the Intranet on that date did not correspond to the new Team duties as of March or July of 2004. Documents on the web site on and before March 26, 2005, confirmed Team members’ assertions that P&Ps had not been updated. There were 13 P&P documents on the web site prior to March 26, 2005. These documents are listed in Table 1.

The Director of BHD was asked to provide and did provide to the Grand Jury copies of the 14 current P&P documents, all showing an effective date of 12/12/03 and a last review date of 7/01/04. These documents are listed in Table 2. The Ventura County Behavioral Health Intranet web site address is http://vcweb/hca/vcbh This address is internal to Ventura County government and is not publicly accessible from the Internet. Ibid. Mental Health Crisis Team and Behavioral Health Management 3 Proc. Effective # Policy Name Date CT1 Domestic Violence Screening 04/16/01 CT2 Screening and Treatment Decision Protocol for Patients Presenting to Hillmont Psychiatric Care 09/24/01 Center Crisis CT3 Transportation of Clients 01/16/02 CT4 Crisis Team Admission Concerns 07/31/98 CT5 Referrals – Crisis Team 01/18/93 CT6 Patient Alert Forms 07/31/98 CT7 Crisis Team – Off Site Services and Physician 07/99 Oversight CT8 Crisis Team – Attending Physician 12/01/01 CT9 Crisis Team – Progress Note 07/99 CT10 Crisis Team Assessment 02/18/93 CT11 Crisis Team – Brief Services Assessment 01/18/93 CT12 Crisis Team Records Assembly 01/16/02 CT49 Client Personal Property Inventory and Search 11/19/03 Table 1. Crisis Team Policies and Procedures as of March 26, 2005 Proc. Effective # Policy Name Date CT3 Transportation Arranged by Crisis Team 12/12/03 CT5 Referrals – Crisis Team 12/12/03 CT6 Patient Alert Forms 12/12/03 CT11 Crisis Team – Brief Services Assessment 12/12/03 CT13 VCBH Crisis Team Telephone Triage 12/12/03 CT17 Initiating a Welfare and Institutions Code Section 12/12/03 5150 Application CT23 Crisis Team HIPPA Standards 12/12/03 CT26 Crisis Telephone Management – Staff Shortage 12/12/03 CT27 Crisis Team Procedure for Using Greyhound Bus 12/12/03 Ticket Purchase Authorization CT30 Crisis Team Dispatch Tracking of Mobile Teams 12/12/03 CT32 Crisis Team Charting and Billing 12/12/03 CT33 Log Book Documentation 12/12/03 CT44 Maintenance of Crisis Team Vans 12/12/03 CT48 Medical Necessity Taking Precedence Over W&I Code 5150 Upon Admission to Non-LPS Designated 12/12/03 Facility Table 2. Crisis Team Policies and Procedures as of April 19, 2005

The documents provided by the Director of BHD did correspond to new Team duties; however, these documents were not on the Intranet and accessible to the employees until April of 2005, nearly 16 months after the recorded effective date of every document. Mental Health Crisis Team and Behavioral Health Management

Neither the Team members nor their supervisors had been informed that procedures were being reviewed or that new P&P documents had been placed on the Intranet in April of 2005. There was no email received by any staff announcing these policy changes.

For instance, the procedure CT1, titled “Domestic Violence Screening,” is a function that Team members believe they are required to perform. However, that function has been removed from the Intranet web site by the Director of BHD without informing the Team staff.

The new P&P documents were back-dated to appear that they had been on the Intranet since at least July 2004, coincident with the downsizing of the Team.

The documents showed inconsistencies and the explanations introduced additional inconsistencies.

Recovered backup files from the Intranet server, provided by ISD, confirmed that the documents now on the Intranet, showing Effective Dates of 12/12/03 and Revision/Review Date of 07/01/04, were actually created by the MA around April 19, 2005.

Multiple backups from ISD were analyzed and there was a consistency in the older version of policies and procedures between December 2003 and April 2005. The explanation of website confusion and duplicate websites was ruled out as a reason for the inconsistent document dates.

Before March 26, 2005, P&Ps for the Mental Health Crisis Team had not been reviewed, updated, or revised for at least a year.

Although the Team staff reportedly asked for updates to the information, it was only after the Grand Jury asked for copies of the policies and procedures that the Director of BHD initiated action to update the files.

The effective dates and review dates of documents are chronologically inconsistent with documents found on backup tapes of Intranet records. The P&P effective dates are also chronologically inconsistent with the events, such as budget cutbacks, that supposedly caused those policy changes.

Of particular significance is a P&P identified as CT30, “Crisis Team Dispatch Tracking of Mobile Teams” (see Attachment 2). This procedure refers to service calls “received by dispatch.” There never was a function known as “Dispatch” within the Team. This procedure was reportedly written by the Director of BHD when it was anticipated that the 24-hour crisis telephone service would be contracted. This documented procedure, as well, was originally effective on 12/12/03, months before the Director reported the effort to contract the Team’s functions.

While there is indication that some of the new procedures had been communicated verbally to the Team over the past year, there are new procedures since April 2005 that were never communicated. Those new procedures also show an effective date of 12/12/03.

It was found that all policies and procedures for the Team were not reviewed or revised in the two years prior to April of 2005. Mental Health Crisis Team and Behavioral Health Management 5

All policies and procedures for the Team were reviewed and revised as of April 19, 2005. In spite of this review and revisions process, none of the Crisis Team P&P documents shows a review or revision date later than 7/1/04.

All Intranet P&P documents in BHD can be changed at will by BHD management. Documents can be backdated with no verifications or management controls. Conclusions C-01. The Team provides a valuable community service, but funding problems in the County required that it be downsized to perform mandated services only. (F-01, F-02, F-05) C-02. The Director of BHD is more directly involved with the Team policies and procedures than the two mid-level supervisors. (F-03) C-03. BHD does not follow its own procedures for maintaining, reviewing, and updating policies and procedures. (F-08, F-09, F-11 thru F-15, F-20, F-21) C-04. There is no document integrity to the policies and procedures on the Intranet, and there is no reliable verification mechanism to ensure that the procedures being followed have been adequately reviewed and appropriately controlled. (F-17 thru F-19, F-24 thru F-26, F-32, F-33) C-05. Employees do not get clear instructions about what is expected of them. There is no well-documented or well-maintained procedure for providing services to clients. (F-16, F-17, F-20, F-21, F-27, F-29, F-30) C-06. There is an inconsistent and contradictory flow of information from the Director of BHD to the employees in the department. (F-20, F-22, F-23, F-25,