Behavioral health hospital audited by OIG

Recently, OIG team members audited a 128-bed behavioral health center in Houston, Texas, to determine if the facility met specific requirements established by state and federal regulations.

During the audit, OIG team members conducted a records review and a site visit to Cypress Creek Hospital. For the report, auditors focused on admission, commitment, and consent requirements for patients receiving inpatient psychiatric services who are enrolled in STAR+PLUS, the state’s Medicaid program for adults with disabilities or who are over 65 years of age.

It was determined that the facility complied with inpatient facility requirements and physician licensing rules. However, the hospital needs to improve processes related to the documentation and timing of its orders, patient consent, and patient evaluations. Specifically:

  • Two voluntary patients who requested discharge were held beyond four hours without documentation of reasonable cause. If the treating physician has no concerns with a voluntary patient’s request for discharge, the patient should be released within four hours. If the doctor questions the release, the doctor must evaluate the patient and determine whether to release or seek court approval by hour 24.  While the patients who requested release were discharged within 24 hours, the physician should have documented reasonable cause to detain the patient for more than the initial 4 hours.
  • All 60 sampled records included an initial psychiatric evaluation. However, ten were not conducted in a timely manner, one was not performed by a physician, and auditors could not determine if one was timely.
  • Most medication orders were prescribed and signed by a physician as required; however, some were either not signed at all or not signed timely. Of the 296 orders for psychoactive medication in the sample, 46 (15.5 percent) were not signed as required. Medication orders not signed by a physician may mean psychoactive medications were administered without verification from the treating physician.
  • Cypress Creek obtained most of the required medication consent forms for psychoactive medication; however, most medication consent forms had errors. Of 137 required medication consent forms tested, 18 were not obtained at all. Of the 119 medication consent forms on file, 13 were obtained after administration and 60 were unable to determine when obtained.
  • All 40 sampled records included a written and signed physician admission order, although not all were completed. Six were not signed in a timely manner, four did not include the date and time, and seven did not include the time.
  • Cypress Creek did not always retain protective custody and emergency detention orders in patients’ medical records. Of the ten involuntarily admitted patients tested, eight records (80 percent) were missing the appropriate court order, which could result in patients being held without authority.
  • Cypress Creek did not ensure all patients acknowledged their rights or their treatment team completed their treatment plans.
    • All 40 records tested contained the Patient’s Bill of Rights form signed by staff who explained the patient’s rights. However, of the 38 forms signed by the patient, all had errors.
    • Of 39 treatment plans tested, all were missing at least one team member’s signature.
  • Texas Administrative Code requires specific elements for voluntary admission and certain therapy consent. Cypress Creek created its own forms for these purposes, but the forms did not contain all the elements required.
  • In three instances, Cypress Creek billed for a patient the day before admission because the patient arrived late at night but was not admitted until the next morning. This resulted in an overpayment of $2,361

OIG auditors provided Cypress Creek with recommendations to help the facility avoid similar errors. In response, the Behavioral Health Hospital agreed with the auditor’s findings and has begun improving its processes.