As Acadia Montana faces criticism and questions about the care it provides kids with behavioral and psychiatric issues, the state of Montana's oversight of the facility is complicated by a startling fact: the person responsible for the oversight and regulation of Acadia Montana is its former CEO, Carter Anderson.
Anderson led Acadia Montana from early 2016 until the middle of last year and has worked at the facility off and on since at least 1996, when it was known as Rivendell of Montana, according to previous reporting.
But Anderson left Acadia Montana in mid-2018 after a rocky tenure that began with concerns from investigators about "the facility's ability to provide a safe and therapeutic environment for the residents" and ended with investigators praising improvements he brought about in patient care.
His new job as of last June: administrator of the Montana Department of Public Health and Human Services' Quality Assurance Division.
As quality assurance administrator, Anderson oversees the division that is "responsible for ensuring that all Montana health care, child care, residential, and youth care facilities comply with the required state and federal standards of care," according to a presentation prepared for state lawmakers this year.
The division also receives and investigates "complaints regarding facility care and services" that allow "the public to play an important role in guarding the safety of the vulnerable populations."
Asked whether the division Anderson leads has conducted a complaint investigation of Acadia Montana in response to recent revelations from Oregon about injected medication and seclusion, Jon Ebelt, DPHHS public information officer, said, "We don't comment on in-process investigations."
Ebelt also declined to speak to Anderson's tenure at Acadia Montana or to make him available for an interview, saying, "Considering his current role, we do not believe it would be appropriate for Carter to go back in time to discuss his time at Acadia."
Gretchen Hommrich, director of investor relations for Acadia Healthcare, also declined to answer questions about Anderson.
In a response to questions about Anderson's role in regulating Acadia Montana, Ebelt said that the facility's former CEO "does not directly oversee" the facility and that it is "simply not the case" that he has "some sort of conflict of interest" in his new role.
"Carter was hired as the QAD Administrator because he was the most qualified candidate," Ebelt said.
But Craig Fitch, acting director of the Montana Mental Disabilities Board of Visitors, which is housed in the Office of the Governor and aims to provide outside oversight of mental health programs in the state, said, "Me, personally, if I were the lawyer for DPHHS, I would recuse Carter Anderson from the investigative process, and I would deputize his second in command there (at the department)."
While a residential licensing program manager directly oversees Acadia Montana and other psychiatric residential treatment facilities in the state and a licensure bureau chief oversees residential, health care, and child care licensing, Anderson is above both of them, overseeing the entire QAD division.
In fact, Anderson oversees the division that ensures Acadia Montana and many other facilities in the state — including everything from the Montana State Hospital to group homes — are licensed, certified, and compliant with a range of state and federal rules.
All told, the QAD's Licensing Bureau licenses and inspects 72 youth care facilities on an annual basis and more than 200 residential facilities serving elderly or disabled adults and treatment services for mental illness and substance abuse. The division will also likely soon oversee 16 private residential treatment programs that have been essentially self-regulating for years.
While Fitch noted that during Anderson's time at Acadia Montana the Board of Visitors saw "an increased willingness to make hard tough decisions" despite a range of challenges, records from Anderson's time as CEO of Acadia Montana indicate investigators found significant issues with how the facility operated.
While no one would speak to his exact start date, Anderson was CEO when investigators from the Alaska Department of Health and Social Services completed a site review in March 2016 that found a host of problems with how the young residents were treated, how the staff were trained, and how administrators failed to follow protocol.
Three residents reported "occurrences of sexualized behavior that varied from over-the-clothes touching of the rear on the playground to a more serious allegation of direct contact with genitals," according to a report prepared by Alaska's Division of Behavioral Health.
Another reported "reviewing 'dirty' pictures with staff." Two said they had been sent outside without shoes. One said they "can't trust staff."
Thirteen of 15 residents from Alaska interviewed as part of that survey said they'd been placed in restraints and into seclusion, and all 13 who had been restrained or secluded "reported something similar to 'it hurts' and 'makes me very angry'," according to the report. Nine said they felt unsafe in the facility, and three said they did not feel safe sleeping.
And all 15 of the residents — 14 of whom were below the age of 12 — stated they didn't like the facility, citing "shots (intramuscular injectable medication, IM), fights with peers, holds, and 'the noise level and how much violence there is'" as their reasons.
While documenting all of the issues at the facility, the Alaska reviewers also noted that Anderson had recently taken over and was in the process of "researching resources to utilize in improving the direct care environment and developing a plan of implementation of those improvements."
Meanwhile, the Alaska DPHSS filed a complaint with Montana DPHHS.
As Montana investigators looked into the facility and reviewed incident reports from a 13-week period earlier in 2016, they detailed a litany of incidents that were not reported to Child Protective Services as required by law. Those incidents included reports that:
• A resident saw porn on a staff member's cellphone and that the same staff member told the resident she was going to adopt the resident.
• A staff member "grabbed" a resident by his shirt and "left a mark on his neck."
• A member "made" a resident "go outside from the children's unit without shoes on because he had been acting out on the unit" and wasn't allowed "back inside for an extended period of time."
• A staff member "was observed on the preadolescent unit dragging one of the residents down the hall by her feet as a way to intervene with an aggressive resident."
• A resident climbed into a ceiling, fell through the ceiling tiles, landed on his side, and had to be sent to express care.
• A resident "kicked through" fire doors, left the unit, and could not be retrieved because "there was not enough staff."
In following up on the State of Alaska's investigating, DPHHS also found that the teen girl who had "reported viewing pornography with a female staff who had told her she wanted to adopt her" was the same teenage girl who "reported an incident involving a nurse who 'basically went off the deep end' and pushed some children and other staff and grabbed one child by the shirt collar."
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"These two incidents have sent the youth back in her therapy and...retraumatized her," according to the DPHHS report.
The June 2016 letter also noted that Acadia Montana had "delayed reporting of incident (sic) involving staff and youth in the program to state oversight agencies" and that it is "unclear if the program has clear guidelines to determine type and severity of incidents that require reporting to state oversight agencies."
Those problems included lobby telephones not working, making it hard for family members to contact staff, and a broken heating system that was leaking antifreeze, leading to buckets filling up with glycol and a resident who "had crawled into the ceiling and was pouring glycol (antifreeze) out of the buckets in the ceiling onto staff members below," according to a complaint that also alleged the facility was generally "out of control."
In addition, the June 2016 letter noted that a follow-up review of incident reports for the 13-week period between Jan. 1 and March 31, 2016, found 128 incidents of physical assaults and 26 incidents of property damage and concluded, "The facility failed to implement significant changes in order to ensure patient safety and reduce the number of serious incidents."
DPHHS's Quality Assurance Division issued a Directed Plan of Correction that required Acadia Montana to "immediately put in place" interventions that would "provide a safe environment"; to submit an updated training program; to "maintain increased qualified profession staff"; to promptly report abuse, neglect, and "aggressive behavior"; and to maintain a census of 85 or fewer patients until "immediate corrective action has proven to be effective."
Two weeks later, Anderson asked for the "immediate removal" of the census cap, citing "initiatives and monitoring systems Acadia Montana has put in place" and concerns that the "existing bed cap will most assuredly lead to denying residents of Montana and bordering states access to quality care."
But when DPHHS reviewed Acadia Montana's Directed Plan of Correction in September 2016, Julie Fink, residential care program manager for the Quality Assurance Division, identified a number of new and persistent problems and ordered the facility to drop its bed count further.
While acknowledging Acadia had made "several changes," the DPHHS observer noted:
• The plan to provide a safe environment "has proven to be ineffective due to a lack of staff and unqualified or lack of training or experienced staff."
• Acadia provided an updated training program plan but did not provide it when it was supposed to, and 24 staff still hadn't completed the training.
• "Acadia has failed to increase professional staff to adequately supervise residents and staff in each unit, implement individual treatment plans, and provide direct (hands-on) staff training."
• The facility's heating system still was not fixed.
The Quality Assurance Division's residential care program manager wrote, "The department has continued to have on-going concerns regarding the facility's ability to provide a safe and therapeutic environment for the residents. Due to a lack of qualified and trained staff, the facility has not been able to maintain a safe environment which is evidenced by the number of Emergency Safety Interventions that occurred."
According to the letter, Acadia's own data showed that between January and August of 2016, those emergency interventions included 500 incidents in one month where medication was ordered to manage patient behavior, up to 276 incidents of restraints being used per month, up to 126 seclusions in a month, up to nine staff injuries in a month due to aggression, and up to 41 peer confrontations in a month. (See related story.)
The letter also cited "an unacceptable number of substantiated abuse by staff," including incidents in which staff dragged a resident by his arms across the floor; intentionally head-butted a resident; intentionally stepped on a kid's hand; pulled a resident's hair, pushed the resident's forehead to the floor, and continued to pull the resident's hair; grabbed a resident by the wrist multiple times; and pushed a kid into a chair and screamed at him to "sit his ass down and he was sick of his shit."
In addition, the letter stated, all eight staff members interviewed said they had "concerns regarding lack of staffing, safety concerns and staff injuries due to lack of staffing." And the letter found that staff had "witnessed other staff 'intentionally setting kids off.'"
While Acadia Montana had already offered to maintain a bed count of 75 or fewer residents in an effort to comply better, DPHHS mandated that this count be adhered to "until all corrective action has been proven to be effective" in order for the facility to "avoid adverse licensure action."
Soon after, the U.S. Occupational Safety and Health Administration conducted its own investigation of incidents that occurred in August 2016 at Acadia Montana.
OSHA investigators found that "on or about August 4, 2016," "Employees were exposed to incidents of violent behavior by clients that have resulted in amputations, contusions, bruising from thrown objects, bites, and injuries to the head and torso from punches and kicks. Employees were exposed to the hazard of physical assaults during routine interactions while working with clients who have a history of violent behavior. The employer has not established or implemented effective measures to protect employees from assaults or other physical violence in the workplace."
OSHA also found that "on or about August 15, 2016," the facility failed to report to the agency "the knuckle-to-tip amputation of an employee's left pinkie that occurred at the Boys Long Hall." The total penalty for the two violations — the first of which was deemed Serious and the second of which was deemed Other-than-Serious — was $15,908.
After the census caps and findings of severe problems by investigators over the course of 2016, Fink found in April 2017 that "Acadia has made significant changes to the facility and program to satisfactorily resolve the issues leading to the (Directed Plan of Correction)."
Acadia was also found to be in full compliance with nearly every element of the Directed Plan of Correction, and the department removed "admission restrictions for the facility."
Over the next year, investigators from Montana and Alaska found small deficiencies at the facility, including damage to walls and flaws in how patient discharge plans were filled out, but they also found areas of improvement.
Interviews with juvenile patients found better impressions of the staff and the therapy, with six of nine youths interviewed by Alaskan investigators in March 2017 speaking "favorably about their therapists, stating 'we talk about my behaviors, and (they) try to help me.'"
The Alaska reviewers also praised Anderson personally, saying, "Acadia Montana has experienced a change of leadership just over a year ago. The new CEO, Carter Anderson, has been instrumental in making notable changes to the program. He shrunk his daily census as he has been working though (sic) staffing and programmatic changes, allowing the facility to have breathing room as the program has strengthened what the facility has to offer."
And the data reported to DPPHS seemed to reflect such strengthening of the facility's offerings.
For example, the number of seclusions dropped 35 percent and the number of emergency medications decreased by 48 percent when comparing the 2016 annual average with the first quarter of 2017 average, according to a DPHHS analysis.
Fitch, from the Board of Visitors, agreed that he also saw Anderson bring about positive changes.
"We witnessed him take very strong action towards a zero-tolerance policy for physical and verbal abuse of the residents and neglect-based issues," Fitch said. "He really stepped up the reporting to us regarding the actions he was taking towards those policies."
Despite such praise, Fitch also noted that certain DPHHS findings during Anderson's time as Acadia Montana's CEO — namely, the report that medication was used to "assist in managing resident behavior" on some 500 occasions in August 2016 — offered some "pretty darn strong evidence" and "a pretty compelling argument that the individuals in charge of determining when a person needed emergency medication may not have been using appropriate judgment."