Unsafe Conditions Required Swift Changes at Alaska Psychiatric Institute
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Commentary

Unsafe Conditions Required Swift Changes at Alaska Psychiatric Institute

"Noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death."

Alaska Department of Health and Human Services (ADHHS) Commissioner Adam Crum, citing authority granted through an emergency provision of state law,  took control of the state’s only public inpatient mental health hospital, the Alaska Psychiatric Institute (API), in February. The move included the decision to enter into a public-private partnership contract to operate the hospital, which the state employees’ union claims violates state law and a collective bargaining agreement, and “takes away jobs from our state workers.”

While the decision to move API to private operation happened suddenly, one would be hard-pressed to label it “unexpected.” The problems under the spotlight in 2019 are just the latest in years of problems at API. In addition to having to face an exodus of all its psychiatrists in January, data from the federal Centers for Medicare and Medicaid Services (CMS) released early in the year cited API for 80 deficiencies over the previous six months—in an 80-bed facility.

All the deficiencies cited by CMS were deemed “immediate jeopardy” situations:

“…entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. These situations must be accurately identified by surveyors, thoroughly investigated, and resolved by the entity as quickly as possible.”

Even more recently, API faced intense scrutiny when the state’s ombudsman released a report in March, which was prompted by the ombudsman receiving 42 complaints from 2015 to 2019 that API employees unlawfully used force, restraints, and violence. The ombudsman found allegations that API had failed to reasonably protect patients from excessive or unnecessary use of force by staff and violence from other patients to be justified. It also concluded API staff had failed to comply with state law regarding the use of physical restraints and seclusion.

The report also cited CMS surveys from the previous few years showing cases of patient neglect, failure to report and keep proper records of incidents, falsification of records, and violations of federal staffing requirements. According to Matt Shuckerow, Alaska Gov. Mike Dunleavy’s press secretary, API was “in imminent danger of losing federal certification” with CMS at the time the privatization decision was made.

Less egregious, but by no means unimportant, API was also under fire for rules governing employees, including unnecessarily costly practices and an overreliance on underqualified labor. The excessive overlap between nursing shifts added to costs, especially over-time, which is defined as any work beyond 37.5 hours in a given week for state employees in the collective bargaining agreement. Additionally, underqualified “on-call” staff were relied upon too heavily, and psychiatric nurse assistants, identified in a 2018 investigative report as “arguably the most critical positions in the hospital,” could be hired without any nursing or even first aid training at all.

API’s problems stem from a variety of factors, however, many are beyond the control of the staff. Therapeutic programming at API fell 76 percent between early 2016 and mid-2018, according to the ombudsman’s report. Direct funding continues to be flat, and Alaska’s Medicaid expansion has resulted in an $8.5 million decrease in the general fund account for behavioral health care grants.

Adding to the difficulties, API has played an active role in filling the void created by the 1997 closing of a state facility for individuals with cognitive and intellectual disabilities. Alzheimer’s and dementia patients now often get sent to API, too, despite the inappropriateness of the environment and the constraint on already limited resources that caring for both groups of individuals require.

Further, the ombudsman report noted “that violence directed toward API staff by patients is an equally serious problem that must be addressed” as “the fear and trauma experienced by API staff contributes to the environment in which decisions about when and how to use restraint or seclusion are made.” While a 2018 investigative report fell short of saying API employees face a “hostile” work environment, its author did agree to the label of “unduly safe” is appropriate.

Alaska Department of Health and Social Services Commissioner Adam Crum’s decision to use his authority to advance a public-private partnership to operate the Alaska Psychiatric Institute was bold. Given API’s string of problems in recent years, many of which continue to be unresolved, one would hard-pressed to say that anything other than “bold” actions could improve API to where it can serve Alaska’s population in the ways it was intended to do so. While one should not expect for the new arrangement to solve all of API’s problems, the shakeups appear to be far more capable of improving API than the status quo would.

Austill Stuart is a policy analyst at Reason Foundation, a non-profit think tank advancing free minds and free markets.