Company Response

June 12, 2024

We recognize the importance of the Senate Committee’s work in this area and share their concerns regarding the treatment of children at Residential Treatment Facilities (RTFs) across the country.  We regret that, despite our cooperation with the Committee throughout the course of a two-year investigation of RTFs, the report is incomplete and misleading and provides an inaccurate depiction of the care and treatment provided at UHS RTFs, as well as the safety of the residents at those facilities.  The report attempts to extrapolate certain incidents and survey reports into a false narrative regarding the treatment provided, environment of care and regulatory compliance at our facilities.  We vehemently dispute this characterization of our facilities.

Residential Treatment Facilities (RTFs) play a vital role in the behavioral health care continuum for youth with special, and often complex, emotional, behavioral and psychiatric needs. Universal Health Services, Inc. recognizes the importance of providing care in our facilities for these children in a safe and therapeutic environment.   The dedicated staff at our facilities work tirelessly to provide the best possible care and treatment to the residents and ensure that each resident is treated with dignity and in accordance with the rules and regulations governing the operation of RTFs.  UHS facilities have been providing behavioral health treatment for over 40 years.

The Role of RTFs in the Care Continuum

RTFs play a vital role in the behavioral health care continuum for youth with special, and often complex, emotional, behavioral and psychiatric needs. According to The American Academy of Child and Adolescent Psychiatry: [r]esidential treatment can help children and adolescents whose health is at risk while living in their community. For example, the programs are helpful for those who have not responded to outpatient treatment, who have education needs that cannot be met in less restrictive settings at their local schools, or who are in need of further intensive treatment following inpatient psychiatric care.[1]

The National Association for Behavioral Healthcare (NABH) further explains: [t]he goal of psychiatric residential treatment is to provide care to children and adolescents with significant social and emotional needs in a non-hospital, highly structured, and therapeutic environment. These settings provide a safe place where individuals can gain stability, support, and treatment for mental diagnoses, substance abuse, intellectual/developmental disabilities, sexual conduct disorders and other disabilities that require stabilization. [2]

UHS RTFs are designed to provide 24-hour, structured therapeutic intervention services to meet the individual needs of each youth, with a special emphasis on learning necessary skills with the goal towards reintegration back to their community through the support of outpatient services.

Admission into our RTF programs require an order from a licensed psychiatrist, advanced nurse practitioner or psychologist who determines that this level of residential care is medically necessary.  Most psychiatrists providing services at UHS RTFs are not employees of the facility but are independent practitioners. Admission to an RTF program may be due to the individual’s failure to respond to a less restrictive environment, or because less-restrictive options are not available in the individual’s community. Further, most of our residents have already received some level of behavioral health treatment and it has been determined by another provider, facility or organization that this child needs continuing RTF care. If the patient is currently in an acute care facility, the treatment team may recommend that residential treatment is appropriate prior to returning to their community.

A patient’s length of stay at an RTF will vary by facility and by individual. At times, unfortunately, a patient will stay in this level of care due to a lack of resources available in their community for ongoing services. At no time, is care not provided to that patient, regardless of the length of stay. Despite the information in the report that resident stays at UHS RTFs are “excessively long”, the average length of stay at our children/adolescent residential treatment programs remained relatively consistent in the past three years. Moreover, continuing stay decisions at RTFs are typically made by coalitions of caregivers inside and outside of the RTF, including not just the attending psychiatrist and treatment team but also family members, guardians, social workers and outside clinicians who will oversee the patient’s transition back to the community.

[1]American Academy of Child & Adolescent Psychiatry, “Residential Treatment Programs”, No. 97; September 2023.

[2] National Association for Behavioral Healthcare (NABH) –  NABH Residential Treatment-A Vital Component of the Behavioral Healthcare Continuum (April 12, 2021)

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Quality is a Core Principle

UHS’ mission, which has been our guiding principle since 1979, is founded on quality patient care. As such, we are committed to being compassionate and responsive to the needs of our patients and their families and utilize evidence-based therapies and treatments to best support those in our care.

• All UHS RTFs in the U.S. are fully accredited by widely respected, independent organizations, including The Joint Commission (TJC) and the Commission on Accreditation of Rehabilitation Facilities (CARF).
• UHS RTFs generally receive a minimum of one annual licensing inspection and most states also have unannounced random inspections in which confidential interviews of patients are conducted, facility tours and milieu observations are completed, clinical documentation is reviewed, and personnel and training files are audited.
• Staffing ratios are also routinely checked, as is compliance with many other service delivery areas (e.g., prescribing practices, medication administration, and educational services, among others).
• Centers for Medicare & Medicaid Services (CMS) audits RTF inspections a minimum of every 5 years, although CMS may conduct complaint surveys at any time. CMS RTF surveys consist of detailed reviews of all policies and procedures pertaining to restraint and seclusion practices as well as emergency preparedness. Surveyors also review medical records to ensure documentation is aligned with CMS RTF regulations.
• All UHS RTFs are required to be in compliance with the regulatory requirements for “Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Facilities or Programs.” 42 C.F.R. § 441.150–441.184 (2019).
• State Medicaid Plans often conduct reviews of compliance with their specific regulations.

Clinical Outcomes

UHS continually monitors and evaluates our care to identify opportunities to improve the quality of our programs. This includes collecting feedback from patients, parents/guardians and clinicians through various evidence-based symptom reduction tools at the time of admission as well as upon discharge and periodically throughout care based upon the length of stay.

In 2023, 84% of participating adolescents and 93% of participating children from our residential treatment programs experienced improvement based on informant surveys. (See UHS’ Our Impact By the Numbers Report – Children/Adolescent Residential Treatment Facilities Edition

UHS also calculates a facility’s Net Promoter Score (NPS) based on responses to, “How likely would you be to recommend our facility to a friend or family member?” On the NPS scale of -100 to 100, our Residential Programs’ collective scores in 2023 were 30.39 which is considered “Very Good/Great.”

“Thank you LifeWorks and your staff for impacting life in such a positive way.”
– Parent of adolescent child, Foundations Behavioral Health – LifeWorks School

Educational Services /Outcomes

We are very proud of the educational services provided to the youth in our care. As will be addressed below, the report’s references to education at UHS RTFs is misplaced and inaccurate. UHS facilities’ educational services are committed to preparing every learner for a successful transition back to their traditional school setting and post-secondary opportunities.

• UHS partners with the appropriate state and local education agencies to thoughtfully plan and allocate educational resources at our RTFs. Educational services may be provided by a local education agency (LEA), or by a charter school or non-public school authorized to operate by the state.
  • Programs typically use state-specific curriculum frameworks, designed to offer transferrable course credit and grades and to meet the special education needs of children with individualized education plans (IEPs).
• UHS facilities comply with all applicable state education requirements for compliance reviews and are staffed by credentialed teachers as well as non-licensed support staff as required by the individualized needs of each school program.
• Many of our academic programs are nationally accredited by Cognia, one of the nation’s leading accreditation bodies for K-12 education.
• Students in UHS RTFs receive an average of 30 hours of educational instruction per week, with slight variation between states and facilities.
• An average of 60% of students at RTFs have an Individual Education Plan (“IEP”) or 504 Plan, with the average across each facility varying between 40 and 65%.
• The UHS Best in Class Academic Accountability System measures and reports on the academic achievement for continuous performance improvement.

In the 2023-2024 school year, UHS academic programs had 138 students complete their high school requirements; almost 30% are headed to post-secondary school, while others plan to enter the workforce.

Collectively, UHS’ educational programs across all UHS behavioral health facilities earned high satisfaction scores from parents and/or guardians:

[3] https://wcyb.com/news/local/multi-million-dollar-youth-trauma-center-opens-in-mountain-city (News 5, January 10, 2024)

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Families are a Critical Component of Therapeutic Intervention

UHS believes it is essential that families/guardians participate in the planning and implementation of their child’s individual treatment program. Having the patient’s family, however defined, is essential to the overall therapeutic process. This is accomplished through a number of opportunities beginning at admission and continuing through discharge.

• Initial Assessment to gather critical information about family history and perception of the treatment needs of the child
• Development of initial treatment plan including goals and interventions for treatment
• Regular family therapy as directed by the treatment team
• Regular review of the treatment plan to include progress towards established goals
• Review of plan for discharge
• Visiting and phone time

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Creating Safe Environments

UHS is committed to providing a safe and secure environment for our patients and staff. This includes being compliant with all appropriate federal, state and local laws, having the appropriate personnel and policies in place and offering employees ongoing training, tools, supplies and equipment they need to mitigate risk and limit the number of unforeseeable events.

UHS Risk Management Program

Directed by PsychSafe, the Patient Safety Organization (PSO) of the UHS Behavioral Health Division, each UHS RTF has a robust risk management program. PsychSafe has been listed for several years with the Agency for Healthcare Research and Quality and provides each UHS RTF with the opportunity to analyze patient safety events to identify learning opportunities around risk mitigation. To our knowledge, UHS is the only behavioral health provider with a listed and qualified PSO. This type of investment and dedication speaks to UHS’ commitment to enhancing the quality of care at our facilities and ensuring the safety of our residents and staff. The tenets of the Risk Management program are borne out of specific elements that are germane to the RTF patient population focusing on risk items including those referenced throughout the Committee Report. Every RTF has a corporate risk manager that provides guidance and support of risk management and mitigation around sexual contact, elopements, and medication errors, to name a few.  Each facility also has a facility-based risk manager that leads these efforts in the facility while focusing on patient safety as their first and most important priority. Eighty-five percent of the Facility Risk Managers have a bachelor’s degree or higher. This is just another example of how UHS leverages the talent of our people to ensure that patients remain at the center of our focus.

Employment Policies/Processes

UHS has formal policies/processes related to employment, including:

• Background Screening: requires criminal, sanction and drug screening as well as education, license and employment verification prior to hire. Additional sanction checks are made by a third party.
• Corrective Action: includes processes and training dedicated to proper investigation for HR and all supervisors/managers.
• Performance Appraisals: calls for evaluations to generally be completed after 90 days of employment and annually thereafter.

Capital Expenditures

Part of providing a safe environment for our patients and staff is our continual investment in facility equipment, expansions and renovations. In 2023, UHS’ capital expenditures for its RTFs totaled $93.5 million.[4] Recent projects include building new replacement buildings for The Hughes Center and Mountain Youth Academy.

• The Hughes Center’s 96-bed replacement facility, including an additional 32 beds, opened in January 2024. The modern facility features educational space and sensory tools to address the special needs of children with autism and intellectual disabilities. The new facility has 14 sensory rooms and five exploratory rooms that include an art room, a study, a music room, a gaming room and an indoor physical activity space.
• Mountain Youth Academy’s new 120-bed Trauma Residential Facility also added 32 beds and opened in January 2024. This facility expansion provides enhanced patient services and allows the facility to better meet the needs of the community by decreasing the wait time for quality mental health treatment for youth ages 5 to 17.

[4] UHS capital expenditures are for the facility (i.e., Alliance Health Center’s $6.1 million cap spend in 2023 may not all have been for The Crossings program. The only exception is North Star Behavioral Health System; only capital spending for its DeBarr and Palmer RTC programs are included).

[5] https://wcyb.com/news/local/multi-million-dollar-youth-trauma-center-opens-in-mountain-city (News 5, January 10, 2024)

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Nurturing our Safety Culture

The care provided by our skilled, compassionate staff is a critical component in the prevention, intervention and healing of our patients. Therefore, UHS takes the training of its staff—and especially clinical staff that directly interact with patients – very seriously.

• New employee orientation includes classroom instruction as well as mentored shifts on the patient care units to fully understand the scope of responsibility for all nursing and clinical staff.
• Additional training includes completion of numerous courses online, including those related to patient safety, skills training, regulatory and quality.
• Employees complete numerous in-person trainings throughout the year based on their role as well as facility and regulatory requirements.
• All Behavioral Health Division patient care staff, regardless of status or role, are trained and certified in various nationally accredited or recognized behavior management techniques. Certification is maintained according to the standards and requirements set forth by these certifying bodies.
• Many UHS facilities augment this training with an evidence-based verbal de-escalation curriculum to support patients in times of crisis.

High Professional Standards

It is essential that staff involved in therapeutic inter­ventions with patients provide adequate modeling of appropriate coping skills, personal behaviors, communi­cation and the ability to develop and maintain interpersonal relationships. Therefore, high personal and profes­sional standards govern staff member con­tact and interactions with patients, other staff and the community.

• UHS personnel who violate the law, UHS or facility policies, or the guidelines described in the UHS Code of Conduct, UHS Compliance Manual and the Code of Business Conduct and Corporate Standards, including the duty to report suspected violations, are subject to disciplinary action.
• Disciplinary actions will reflect the severity of the noncompliance, up to and including immediate termination.
• Adherence to compliance and ethical standards will be part of the job performance evaluation criteria for all personnel.
• The UHS Code of Conduct clearly indicates that staff are not retaliated against for making a report to the Compliance Hotline or through any other mechanism to raise concern.

Continued Focus on Quality Improvement

There are mandated 15-minute wellness checks at all RTFs. Further, UHS has been testing out technological improvements (e.g., electronic medical record documentation of rounding, wearables) to help employees keep patients safe and secure.

• In the Fall of 2023, the Behavioral Health Division expanded and enhanced its focus on Trauma Informed Care (TIC) across the entire Division.
• As of May 2024, approximately 6,300 RTF staff members have completed formal TIC training. Training participants included clinical and educational services staff, as well as RTF staff from other departments (e.g., Intake, Human Resources, Nutrition).

Patient Grievance Reporting

All UHS RTFs ensure that patients are informed of their rights and all available procedures for reporting any misconduct as soon as they arrive at the RTF. Patients are also able to report their concerns via the UHS Compliance Hotline/platform. However, patients are more likely to reach out to their Patient Advocate or other means to report any grievances. UHS RTFs prohibit any retaliation against patients that may make a complaint or submit a grievance.

• CMS requires a very specific process to address patient grievances including how and when to follow-up with the patient after a review of the grievance itself. Facility Patient Advocates (and leadership, if needed) handle patient grievances in accordance with these CMS requirements.
• Similarly, for grievances, once a report from an employee or patient is received, an investigation will be initiated to determine the nature, scope and duration of wrongdoing. If the allegations are substantiated, a plan for corrective action is developed and, when necessary, remedial action is implemented.

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Testimonials

Cedar Springs Hospital

“Our returning patient had a lot of great feedback during his time spent in Cedar’s New Choices program, and we are very appreciative of the care given by Cedar Springs.”
– Referral Source in California

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San Marcos Treatment Center

“Every individual that I have been in contact with at San Marcos has been nothing but AMAZING! San Marcos is my go-to for the littles!!”
– Referral Source in Texas

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Alliance Health Center

“I am pleased that you all offer excellent care! I referred patients there and now they are home and doing well. I am happy to have Alliance to call whenever anyone in my county needs mental health or addiction treatment!”
– Referral Source in Mississippi

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Compass Intervention Center

“I feel at ease knowing my patients I refer to Compass will be supervised and have their mental health needs met. Also, my patients’ parents feel comfortable and are educated working with mental health professionals who educate and include them in their child’s treatment plan. [Staff members] are the dream team with astronomical work ethic.”
– Referral Source in Tennessee

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Foundations for Living

“Foundation for Living remains to be one of our “go-to/preferred providers” for crisis level of treatment and care for our Summit County youth. Very timely receipt of monthly reports, quarterly reports. I appreciate the planned monthly treatment meetings.”
– Referral Source in Ohio

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La Amistad Behavioral Health Services

“I’ve had many patients go through La Amistad’s programs. All of them had successful outcomes and spoke highly of their care. I recommend any patient in need to La Amistad and will continue to refer.”
– Referral Source in Florida

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North Spring Behavioral Healthcare

“The youth we placed at North Spring was coming from an Assessment Diagnostic at Intercept and had had some behavioral/aggression issues during her stay. We were having some difficulties finding placement for her but were excited to receive an acceptance from North Spring. During her stay, I always received timely links for her treatment team meetings. At her meetings, I noticed that she received lots of positive reinforcement from her case manager. [Staff member] was an excellent advocate for her, saw her strengths, and reassured her that she was in control of herself and her behaviors. When she was ready to discharge home, the caregivers were excited for her return, which was something we would have never expected at the time of her admission.”
– Referral Source in Virginia

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Wyoming Behavioral Institute

“Thank you for the help with the patient and the communication with the parents. Everyone was very happy with the care, so I just wanted to share that again. Thank you for the help and we look forward to continuing this partnership.”
– Referral Source in Wyoming

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Addressing the Committee Report

First and foremost, we acknowledge that there have been incidents over the years at some of our facilities where residents have suffered harm. Such incidents are unacceptable and are contrary to the goals and expectations of our facilities. Any harm perpetrated by any staff member is not tolerated and directly contradicts the expectations of employment, the extensive training provided as well as the policies, procedures and protocols of the facility.

Per UHS’ policies and practices, allegations from individuals and survey findings from regulators are promptly investigated and, when appropriate, action is taken. Deviation from our high standards is not tolerated, and in most cases, non-compliant behavior by staff results in termination, along with an action plan to drive continuous improvement (e.g., retraining, refinement of protocols, changes to future hiring practices, etc.).

Notwithstanding, the Committee Report is incomplete, misleading and provides an inaccurate depiction of the care and treatment at UHS RTFs as well as the safety of the environment at the facilities. None of the Committee staff involved in the investigation of this matter visited any UHS RTF despite being invited prior to publication of the report.

We believe that the report provides a false narrative regarding the quality of care at UHS RTFs.[6]

UHS welcomes the opportunity to provide its expertise to legislators at every level to improve oversight and regulation of RTFs. We provided the Committee with extensive documents and information in hopes that this would strengthen their analysis of, and recommendations regarding, the crucial care provided to children around the country. We are deeply committed to providing young people with effective treatment, compassionate care, and a nurturing environment, but are well aware that no organization, including our own, is perfect. We are always looking to improve the care and safety of the patients entrusted to us, which is why the incomplete and misleading Committee Report represents such a missed opportunity to actually improve patient care.

The following attempts to address and respond to the major themes and issues raised in the Committee Report relating to UHS RTFs. We will not address each and every matter, incident or survey cited in the report.

Regulatory/Accreditation Surveys

The Committee Report cites various regulatory and accreditation surveys of UHS RTFs over several years. Merely aggregating survey findings across 59 facilities over a multi-year period without delineation of severity does not equate to the narrative of poor quality of care at those facilities or across the UHS RTF spectrum.

All healthcare facilities are subject to surveys (essentially inspections) by state and federal regulatory agencies as well as accreditation bodies in the ordinary course. The job of every regulator conducting a survey is to identify areas for improvement at a facility and UHS RTFs greatly benefit from their careful review. The Committee Report assumes that the existence of a report and all allegations and findings therein are evidence of deficient care.  However, the severity or seriousness of the deficiency varies within the reports and with each survey. The Committee Report failed to provide any information as to the severity of the findings and leaves the reader with the impression that all findings were significant or serious and/or that they were never resolved by the facility. A review of the documents shows that many of the citations were of a lower level of severity/concern. As an example, the report cites findings by The Joint Commission at various facilities but fails to mention that notwithstanding those findings, the facilities successfully resolved the concerns identified and in each instance were fully re-accredited. While UHS strives for 100% compliance with all regulatory requirements and quality standards, it is unrealistic for any healthcare facility to achieve such a goal.

All UHS RTFs are fully accredited by either The Joint Commission (TJC) or the Commission on Accreditation of Rehabilitation Facilities (CARF) and are in good standing with all regulatory agencies.  All 59 facilities hold state Medicaid numbers and many hold out of state Medicaid numbers requiring contracts and compliance with individual plan provider manuals. Each State Medicaid plan has its own requirements which vary from state to state. This is another level of oversight that each RTF has which may include on-site visits or desk reviews to demonstrate compliance. Additionally, all facilities are in compliance with the Federal Regulations (42 C.F.R. §§ 483.350-483.376) governing restraint and seclusion as well as emergency preparedness at RTFs.  Further, all 59 UHS RTFs are in good standing with their licensing bodies in their respective states.[7]

From the period of 2018 through 2022, UHS RTFs experienced approximately 827 regulatory surveys.  Included in that total is greater than 200 surveys conducted by either TJC or CARF. At no point during that time frame did a UHS facility fail to maintain full accreditation. As part of the accreditation process with TJC, a facility must demonstrate compliance within 45 days to maintain accreditation. The report references many TJC surveys but does not indicate full compliance was achieved 100% of the time. Similar results exist with those facilities accredited by CARF.

The remaining facility surveys are state licensing reviews and payer audits. The total also includes reviews conducted by other state agencies charged with reviewing allegations of abuse and neglect, reported by UHS RTFs. When there have been findings, UHS facilities have corrected those findings.

As one example of a misguided attempt to impugn the regulatory compliance of one of UHS’ RTFs, the Committee Report references a letter received by a Division VP of UHS indicating that there were incomplete behavioral treatment plans and crisis plans for children at the facility. It failed to mention that the facility “continues to MEET the family first requirements for QRTP (Qualified Residential Treatment Program) and did not require a plan of correction”. That same letter closes with “DCFS [Department of Children & Family Services] is grateful for your partnership in our collective efforts to improve outcomes for Illinois’ most vulnerable children and families.”  This is an example of failing to provide full context to a regulatory matter and drawing an erroneous conclusion based upon an incomplete review of the document.

As was described to the Committee staff during the 4 ½ hour interview in May of 2024, all regulatory survey findings are presented to various corporate departments of UHS of Delaware, Inc., the UHS subsidiary that provides supportive resources to the facilities. Resources are then deployed to the facilities to assist in developing plans of correction, implementing those plans and ensuring continued compliance with the plans as well as other regulatory and quality requirements. The staff failed to include this information in its report. When assessing a facility’s or system’s commitment to quality and compliance, merely citing survey reports without discussing the efforts made to remediate any deficiencies does not provide an accurate or complete picture of the performance and focus on patient care.  One reading this report would draw the conclusion that each of these facilities are out of compliance with the regulations. Without the evidence of the corrective action plans, which were provided to the Committee as part of their document request, this presentation is fundamentally inaccurate and disingenuous. In many cases, the facility is resurveyed to confirm compliance with the corrective action plan. In most cases, that closes the survey cycle. In all of these circumstances, each facility successfully resolved the identified concerns.

Notwithstanding, we view all external agency and accrediting surveys as an opportunity to enhance the quality of care at our facilities as well as improve our operations. In addition, we have engaged our own external consultants at times to assess our facilities and provide recommendations on quality enhancement initiatives and to improve regulatory compliance.

Staff Incidents

The Committee Report cites isolated incidents over a several-year period of inappropriate sexual contact between staff and residents. To be clear – UHS’ position is that one substantiated case of sexual relations or assault as well as any physical abuse by a staff member towards a patient is one too many. UHS has a zero-tolerance policy for such behavior and those incidents have no place in any treatment facility. In all of the instances cited in the report where the allegations were substantiated, those staff members were ultimately terminated.[8]

Notwithstanding, context to these incidents is also relevant when viewing UHS as whole in relation to the safety of our RTFs.  The Committee Report referenced five incidents at three facilities over a 6-year period (2017-2022) of inappropriate sexual contact with residents within the facility. During that 6-year period, UHS RTFs treated approximately 19,000 patients spanning approximately 7 million patient days. Internal data for the past 4 years on these types of incidents establishes a patient risk rate[9] for this type of harm was 0.003.[10]  Again, while even one such incident is one too many and UHS’ expectations are zero, such a risk rate does not equate to the narrative of a pervasive problem and/or an unsafe environment for residents at our facilities.

As to the incidents of staff physically harming residents at any of our facilities, the report once again identified incidents to create the narrative of unsafe environments at large at UHS RTFs without any context as to the number of patients treated across the UHS RTF spectrum during that time. Over the past three years, based upon the number of patients treated during this time period, the patient risk rate of physical harm from staff was 0.015. Again, while even one such incident is too many and UHS’ goals and expectations are zero, such a risk rate does not equate to the narrative of an unsafe environment for residents at our facilities due to staff harm since 99.985% of our residents across the UHS RTF continuum never encounter this type of situation.

As referenced, through its Patient Safety Organization (PSO) process, UHS tracks the number of serious incidents per year where our staff has acted in a manner inconsistent with our training, policies and procedures, and protocols with respect to interactions with residents that result in harm. With almost 13,000 employees working at various UHS RTFs, the average annual rate of staff involved with serious incidents with patients is 0.005% of the staff.  In all these instances, disciplinary action was taken including and up to immediate termination dependent on the circumstances and actions involved. Once again, our expectations are that there be ZERO incidents. However, this data contravenes the false narrative, depicted in the Committee Report, that UHS RTFs are unsafe environments for our residents based upon staff interactions. In fact, this data supports the efforts of UHS to hire, train and evaluate our employees’ actions in accordance with our expectations for the safety and well-being of our residents.

As referenced, UHS closely monitors all such matters and if we see that a facility has an increase in the number of events, we will deploy additional resources (both internal and external) to address the situation and remediate any issues, including, but not limited to, changing leadership at the facility.

As described and provided in detail to the Committee staff during the course of their investigation, UHS facilities utilize an extensive hiring and training regimen for all employees – especially those that will interact directly with our residents. All employees go through screening prior to hiring that includes background checks by a third party. Every new employee undergoes a minimum of 40 hours of initial classroom and on-line training. This training includes: therapeutic boundaries with patients, physical management techniques, patient observation rounding and verbal de-escalation, to name a few.  Employees in training will then be proctored on the floor for a period of time before they are allowed to work independently with the residents. There is updated and annual training required for all employees on a myriad of quality, clinical and resident safety issues routinely.

Patient-on-Patient Abuse

The Committee Report attempts to portray pervasive patient-on-patient violence (sexual and physical) due to incidents cited in the report over several years. Once again, greater context will provide a more accurate picture of the state of the patient environment at UHS RTFs. Over the past 5 years, the average rate of patient-on-patient incidents resulting in serious harm across the UHS RTF spectrum was 0.1072 per 1,000 patient days.[11] Further, when assessing from a resident risk rate, the resident risk rate for significant physical harm was 0.01. The resident risk rate for sexual contact or acting out was 0.027.[12]

To be clear, even one substantiated incident is one too many. All UHS RTFs have protocols and practices in place to minimize the chance of sexual encounters or assaults between residents. We acknowledge that when the protocols and safety measures put in place are not followed by our staff, these types of isolated and unfortunate incidents can occur. Further, when an incident is reported and investigated, the facility promptly acts to remediate any deficiencies and enact measures to prevent any recurrence. The primary focus, in the event of an allegation, is patient safety and protection against any harm. While there are not national benchmarks for this type of conduct, we believe that our rate would compare favorably to similar RTFs in similar locations treating a similar patient population. This is an area where greater data reporting may be of benefit to the industry, our residents and their families.

Restraints and Seclusion

The Committee Report inaccurately depicts UHS RTFs as overutilizing restraint and seclusion techniques to manage residents. This, again, is an incomplete and misleading characterization of the usage of restraint and seclusion at UHS RTFs. The report also references instances of improper restraint techniques being used. In fact, in UHS RTFs, restraint and seclusion are to be used only in limited circumstances when a resident is in danger of harming themselves or others and in need of greater support. In those circumstances, the use of each intervention is carefully monitored and documented.

First, UHS RTFs have comprehensive policies and procedures regarding the use of restraints and seclusion.  Consistent with federal guidelines allowing restraint and seclusion at RTFs in certain circumstances (42 C.F.R §§ 483.350-483.376), UHS has standardized policies and procedures in place pertaining to restraint and seclusion practices, which are required at each UHS RTF. Some individual states have additional regulations that govern these procedures that are implemented by the facilities as well. A summary of the general policy statement of UHS facilities is as follows:

Consistent with the aforementioned policy and other applicable regulations, we offer a number of trainings on restraint and seclusion to relevant staff as needed. As described in more detail below, training includes instruction on both verbal and physical de-escalation and management techniques, ongoing monitoring of the patient’s health and safety and properly choosing the least restrictive intervention among many others.

UHS policy requires clinical and nursing staff, upon hiring (and semi-annually thereafter), to receive mandatory training on the proper use and monitoring of physical and chemical restraints and seclusion. The training includes an 8-hour training class on verbal de-escalation techniques, followed by a 6-8 hour class on physical management techniques. Both classes are competency based and require the completion of a test as well as demonstration of learned skills.

Direct care staff are required to attend a nationally recognized physical management training program and show evidence of competency related to participating in a code response situation, application of restraints, or the monitoring, assessment and care of a resident in restraints or seclusion. This course is taught by certified trainers qualified to teach these skills at each facility. Physicians and other licensed independent practitioners (LIPs) authorized to order restraint or seclusion are required to have a working knowledge of the facility’s policy regarding the use of restraint/seclusion.

Nurses who are authorized by the state to conduct the One Hour Face-to-Face Evaluation (post seclusion/restraint) are also required to receive additional training and demonstrate competency to conduct both a physical and behavioral assessment of the resident.

In order to minimize the use of restraint/seclusion, staff involved in the use of restraint/seclusion are required to receive on-going training and must demonstrate an understanding of:

• The underlying causes of threatening behaviors exhibited by the individuals they serve, including resident and staff behaviors, events and environmental factors
• Individuals that may exhibit an aggressive behavior that is related to a medical condition and not to an emotional condition, such as threatening behavior that may result from hypoglycemia
• The impact of staff behaviors on the behavior of residents
• Alternative techniques to redirect a resident, engage the resident in constructive discussion or activity, or otherwise help the resident maintain self-control and avert escalation
• Recognizing and responding to the signs of physical and psychological distress in individuals who are being held, restrained or secluded
• The use of first aid techniques and certification in the use of cardiopulmonary resuscitation (CPR), including periodic recertification
• The process or need for all team members to be able to challenge any staff using an inappropriate procedure and stop the physical restraint intervention, reposition the resident or change staff as needed to maintain safety

Staff who are authorized to perform 5-minute assessments (a requirement in RTFs) and/or who monitor individuals in restraint/seclusion are required to receive additional training and demonstrate competence in:

• Taking vital signs and interpreting their relevance to the physical safety of the individual in restraint/seclusion, including respiratory status
• Recognizing nutritional/hydration needs
• Checking circulation and range of motion in extremities (restraint only)
• Checking skin integrity (restraint only)
• Addressing hygiene and elimination
• Addressing physical and psychological status and comfort
• Assisting individuals in meeting behavioral criteria for the discontinuation of restraint/seclusion
• Identifying specific resident behavioral changes that indicate readiness for the discontinuation of restraint/seclusion
• Recognizing signs of any incorrect application of restraints
• Recognizing when to contact a medically trained LIP or emergency medical services in order to evaluate and/or treat the resident’s physical status

A nurse, in the absence of a physician, is authorized to initiate restraint or seclusion use and perform evaluations/reevaluations of individuals who are in restraint/seclusion to assess their readiness for discontinuation or establish the need to secure a new order. In addition to the training outlined above, nurses are required to be trained and demonstrate competence in:

• Recognizing how age, developmental considerations, gender issues, ethnicity and history of sexual or physical abuse may affect the way in which an individual reacts to physical contact
• Choosing the least restrictive intervention based upon an individualized assessment of the resident’s medical and physical status/condition
• The use of behavioral criteria for the discontinuation of restraint or seclusion and how to assist individuals in meeting these criteria

Nurses who are permitted to conduct additional evaluations of the individuals in restraint/seclusion by CMS, The Joint Commission (TJC) and state regulations are required to receive training and demonstrate competency in the following:

• Use of less-restrictive measures such as redirecting the resident’s focus, employing verbal de-escalation and separating resident from group or community
• Evaluation of the resident’s immediate situation
• Evaluation of the resident’s reaction to the intervention
• Assessment of the resident’s medical and behavioral condition
• Assessment of the need to continue or terminate the restraint/seclusion

In addition, our policy dictates that we, as appropriate, regularly solicit and receive feedback from individuals who have experienced restraint/seclusion to enhance the training provided to staff. Whenever possible, such residents contribute to the training and education curriculum and/or participate in staff training and education. This is a component of the required debriefing that occurs following each episode of restraint or seclusion. The facility gathers the resident’s feedback and updates training based upon the feedback, consistent with the requirement in the rule.

All individuals providing training must be qualified as evidenced by education, training and experience in techniques used to address residents’ behaviors and/or perform various assessments required by hospital policy. The following are requirements for each type of training:

• All trainers for the aggression management program must be currently certified as a trainer by a nationally recognized aggression management program
• Nurses, approved by the facility’s nurse executive (based on education and psychiatric experience), are authorized to provide relevant training
• CPR must be provided by an instructor certified by a nationally approved evidence-based training program
• Physicians experienced in the use of restraint/seclusion may provide training for the One Hour Face-to-Face Evaluation

While we acknowledge there are instances when inappropriate restraint techniques are utilized (sometimes resulting in harm to a resident), the Committee Report presents a false narrative that such incidents are commonplace at UHS RTFs. The reality is that such incidents are rare.  When there are episodes of inappropriate restraint techniques applied, remedial and/or disciplinary action will be taken against those employees involved.  We expect all employees to only utilize approved restraint techniques in appropriate circumstances.

The restraint usage at issue is staff members physically holding or restricting a resident’s movement in order to help the resident regain self-control when they are more dysregulated and are a danger to themselves or others. To be clear, UHS does not use mechanical restraints. Further, the use of restraints and seclusion are only allowed in the event of imminent risk of harm. UHS RTFs receive specific training on the definition of imminent risk. While UHS RTFs focus extensively on reducing and minimizing the use of restraints, it is necessary at times to utilize these techniques to protect the patients. As stated, if our staff is found to have utilized inappropriate restraint techniques or usage, disciplinary action will be taken, including immediate termination, if warranted. Re-training may also be provided as appropriate.

Through its PSO, UHS tracks the use of restraints as a mechanism to enhance our clinical operations and reduce their utilization. We provided data to the Committee staff on the restraint usage at the RTFs in accordance with the Patient Safety Quality Improvement Act (PSQIA). In describing this data, the Committee Report made misleading and unsubstantiated claims and failed to provide greater information about the data. The Committee Report claimed that in 2022 there were 35 facilities with “double digit” restraint rates as if to indicate that was excessive. However, there is no nationally established standard or rate at which restraint usage per 1,000 patient days is deemed excessive at this level of care. Based upon our years of experience in the industry, our internal benchmark rate for restraint usage is 16 per 1,000 patient days. The average restraint rate for all UHS RTFs for 2022 was 15.63 –below the benchmark. In 2022, 39 of the 59 facilities (66%) had restraint usage rates below that benchmark. Further, 44 out of 59 facilities (75%) had restraint usage rates below 20 in 2022.

Additionally, UHS has undertaken a concerted effort over the past few years to significantly reduce the usage of restraints in our facilities. In fact, for 2022, 36 out of the 59 RTFs referenced by the report saw a decrease in restraint rate/usage (some being substantial).

UHS has utilized an evidence-based approach to overall restraint use by adopting the principles developed by the National Association of State Mental Health Program Directors’ (NASMHPD) Six Core Strategies for Reducing Seclusion and Restraint Use© which focuses on the following:

1. Leadership Toward Organizational Change
2. Use of Data to Inform Practice
3. Workforce Development
4. Use of Seclusion/Restraint Prevention Tools
5. Consumer Roles in Inpatient Settings
6. Debriefing Techniques

By ascribing to these guiding principles throughout the UHS BH Division, the results have been significant.

The use of medication as restraint (commonly referred to as chemical restraint) is governed by the same set of rules as physical restraints (holds) and seclusion.  All medications, regardless of their use, are ordered by a physician or a nurse practitioner, licensed and privileged to provide care at the RTC. When less restrictive interventions do not support the patient in regaining self-control, medications may be an option to assist. There are states that do not allow the utilization of medication as restraint and UHS facilities comply with that requirement. UHS RTFs have policies and procedures regarding the use of chemical restraints to ensure appropriate utilization, management and oversight. As with other restraints, chemical restraints are never to be used as a form of punishment or for staff convenience. In any circumstance where lack of compliance is identified, the RTF creates a plan of correction and resolves the concern.

The seclusion data we provided the Committee staff is even more compelling. The Committee Report merely states that one UHS RTF had a seclusion rate of 12.63 per 1,000 patient days with no other context around this statement. However, the report does indicate that 36 of the 59 RTFs (61%) had a seclusion rate of 0.  What the report failed to mention was that of the remaining 23 facilities, 13 had a rate of less than 1. That means 83% of UHS RTFs had a seclusion usage rate of less than 1 per 1,000 patient days.

The report inaccurately states that during an interview with UHS Leadership, we stated that we believed there were circumstances in which it might be necessary to both chemically restrain and seclude a resident. That is not an accurate representation of the interview nor a statement made by UHS Leadership. Committee staff asked whether there were circumstances where it would be necessary to use a chemical restraint in conjunction with a physical restraint, to which we replied there would and which is allowed by federal regulations. We were not asked about chemical restraint in conjunction with seclusion. As such, the statement in the report attributed to UHS Leadership on this issue is inaccurate.

While UHS is focused on reducing seclusion usage, it is a necessary intervention utilized to protect residents and to help them regain composure and emotional control. Staff are trained never to use seclusion as a punishment or for staff convenience. The requirements for staff monitoring of a patient in restraint and/or seclusion are significant which is counter to any suggestion that seclusion is utilized to address staffing concerns.

There are variances amongst the facilities as to the usage of restraints and/or seclusion. The variances are due to the patient populations at those facilities and the mental health pathologies of those residents as opposed to failures of the staff or lack of appropriate policies and procedures at the facilities.

This is an area where greater industry benchmarks may help establish standardized rate targets to assist all RTFs in reducing and managing restraint and seclusion usage. A national metric exists for restraint and seclusion utilization in inpatient psychiatric settings but it does not exist for the RTF level of care. UHS would support efforts in identifying an appropriate metric that would provide greater understanding of its utilization. Currently, there is no reliable way to understand the utilization of restraint and seclusion in RTFs. As the Committee Report is written, it provides the reader with information that is meaningless without this appropriate context.

UHS RTFs strive to consistently report restraint events as required by state rules and regulations, where they exist. In the rare instances where facilities have not complied with reporting obligations, remedial action has been taken.

Many of the issues raised in the report by the Committee staff around restraints dealt with documentation failures as opposed to improper use of restraints. As will be addressed in more detail below, documentation errors or omissions do not indicate the appropriate treatment was not rendered or that protocols were not followed.

Suicide and Ligature Risk

The report describes survey citations around suicide risk assessment documentation, protocols and ligature risks. Ligature is defined as “a thing used for tying or binding something tightly” and in this circumstance largely means tied to a fixed point in a physical environment. The Committee Report once again attempts to create a false narrative that UHS RTFs fail to take appropriate clinical and environmental actions to prevent suicides in our facilities. As part of the review of each facility’s physical environment, a ligature risk assessment is completed and issues are addressed based upon that assessment.

The Committee Report also references certain instances where surveyors have pointed out ligature risks.  In each of those circumstances, the facility immediately mitigated those risks – sometimes while the surveyors were on site. In fact, in one specific circumstance, raised during the Committee interview, the survey report indicated that corrections were made prior to the surveyor leaving the building.  Further, as was described to the Committee staff, we have environmental services staff at all facilities who constantly assess and remediate any perceived, reasonable ligature risk. Our staff are trained on assessing ligature risks and notifying the appropriate individuals to remove such risks once identified.

Patients are assessed regularly throughout the course of their care at an RTF. Those residents who are assessed as a high suicide risk should not be treated in an RTF setting. Those individuals require a higher level of care and should be in an acute inpatient facility. Notwithstanding, our RTF facilities have policies and procedures to assess suicide risk in our patients as well as interventions and safety measures to prevent suicides in the facility. We also provide training to all staff on assessing suicidality and maintaining vigilance in looking for any signs of suicidal behavior or ideation via the use of standardized industry developed and endorsed tools. As mentioned in our prior responses and our interview with Committee staff, one additional intervention at all UHS facilities, is the 15-minute observation checks done 24-hours a day, 7 days a week for all residents, regardless of assessed suicide risk.

The Committee Report mainly references documentation errors or omissions regarding suicide assessments. Those issues do not mean that our residents are in an unsafe environment.

Suicide risk assessment is a major focus of our efforts to keep our residents safe. We believe that our facilities are safe. UHS is proud to be a 10-year partner with the National Action Alliance for Suicide Prevention in their efforts to reduce and eliminate suicide throughout the country. Some of the work completed through this partnership include the development of strategies to support safer care through training, data management, care transitions and workforce development to name a few.

Staffing

The report attempts to create the false narrative that UHS RTFs are systemically understaffed. UHS RTFs comply with all state regulations that provide for specific staffing ratios. In addition, in those states that do not have ratios, UHS RTFs ensure that staffing numbers meet the requirements for effective treatment and a safe environment. Our facilities utilize a multi-level assessment and evaluation process to determine appropriate staffing levels based upon a myriad of clinical and operational factors. These staffing levels are then regularly and routinely reassessed and updated to ensure the appropriate staffing levels are utilized. We acknowledge that due to sudden and unforeseen circumstances, staffing numbers may be below ratio or less than what a facility staffing plan requires for a limited time period on a particular unit. This can happen when there are unexpected call-outs by staff without giving sufficient time for the facility to fill the vacancy. We have processes in place to mitigate those situations, including closing beds or stopping admissions to ensure that the staff available can provide the necessary care and ensure a safe environment for each resident. However, there is not systemic or endemic understaffing at UHS RTFs.

Like all health care facilities, we encountered significant staffing issues in terms of retention and hiring during COVID and in the rebound years. However, we have dedicated substantial resources and effort toward recruiting, hiring and retaining qualified and talented staff and have seen marked improvement over the past year as we have emerged from the COVID impact on staff and employee retention.

As mentioned above, we employ stringent screening protocols including background checks on all employees. Staff at our RTFs undergo extensive training on our policies, procedures and expectations prior to interacting with any residents. Many of the incidents described in the report are episodes where staff failed to comply with our policies, protocols and training. In all circumstances where such events occur, appropriate disciplinary and remedial actions are taken.

Medical Record Documentation

Many of the survey issues noted in the Committee Report involve medical record documentation errors or omissions by facility personnel on a variety of issues. First, it is not uncommon for all health care providers and facilities to have documentation lapses, errors and omissions. Second, while there may be omissions in various aspects of the medical records, that does not mean that the appropriate treatment, intervention or care was not provided. In the behavioral health/RTF space, providers often encounter challenges meeting the onerous record keeping requirements that vary by state and by payer. Once again, such lapses do not equate to a failure to provide appropriate care or ensure the safety of our residents. The report attempts to improperly aggregate documentation errors and omissions in medical records at select facilities to falsely equate to the quality of care or patient safety at those facilities. While we acknowledge the failure of technical record documentation at some of the facilities referenced in the report, we dispute the narrative of deficient care or safety due to record errors or omissions.

The Committee Report discusses treatment interventions as reflected in the medical records.  While we acknowledge documentation errors and omissions involving therapeutic interventions at selected facilities based upon survey reports, we dispute the attempted narrative that our residents are not getting the requisite level of care during their treatment stay from admission through discharge.

UHS spends significant effort and resources training our staff on proper and thorough medical record documentation. We also conduct regular audits of medical records to ensure compliance with record keeping requirements including those required for documentation of the use of restraint and seclusion.

UHS has also begun implementing electronic medical records (EMR) at our facilities. With respect to the RTFs, we have installed EMR systems at 15 facilities to date, with more planned. We are confident that this investment will enhance the quality and completeness of our medical record documentation to fully reflect the care and treatment provided.

Length of Stay

Length of stay at a UHS RTF is dependent on a number of factors and ultimately determined by the attending physician in consultation with the treatment team. Length of stay is a metric that is clinical in nature and focuses on the individual needs of each patient meeting appropriate medical necessity criteria.  In addition, as referenced above, others outside the treatment team will also be involved in length of stay determinations including family members, guardians, social workers, and outside clinicians who will oversee the patient’s transition back to the community. Given that each of the 59 UHS RTF programs has multiple State Medicaid contracts with their own medical necessity review criteria, length of stay continues to be driven by the treatment team.

Each RTF has a unique length of stay based upon the patient population served. There are occasions where there are not resources available in the child’s home state for follow up care and there is no other location that can safely treat the child. At no time would a UHS RTF discharge a patient without a discharge plan in place. On average, the length of stay at our RTFs for children and adolescents is 137 days and has been fairly steady across the last several years. There are outliers based upon clinical presentation and program structure. The Committee requested the minimum and maximum length of stay, which is not a standard metric used in this industry, and it did not request information about the corresponding circumstances that would explain the lengths of stay for those patients. Minimum and maximum length of stay data points are of limited value in assessing quality of care or treatment efficacy.

Education

The Committee Report incorrectly and falsely states that UHS RTFs failed to provide adequate and appropriate education to our residents.  This is false.

UHS facilities’ educational services are committed to preparing every learner for a successful transition back to their traditional school setting and post-secondary opportunities.

• UHS partners with the appropriate state and local education agencies to thoughtfully plan and allocate educational resources at our RTFs. Educational services may be provided by a local education agency (LEA), or by a charter school or non-public school authorized to operate by the state.
  • Programs typically use state-specific curriculum frameworks, designed to offer transferrable course credit and grades and to meet the special education needs of children with individualized education plans (IEPs).
• UHS facilities comply with all applicable state education requirements for compliance reviews and are staffed by credentialed teachers as well as non-licensed support staff as required by the individualized needs of each school program.
• Many of our academic programs are nationally accredited by Cognia, one of the nation’s leading accreditation bodies for K-12 education.
• The “UHS Best in Class Academic Accountability System” measures and reports on the academic achievement for continuous performance improvement.

In the 2023-2024 school year, UHS academic programs had more than 138 students complete their high school requirements; almost 30% are headed to post-secondary school, while others plan to enter the workforce.

To assist in the delivery of quality educational services, we developed the “UHS Best in Class Academic Accountability System.” The primary goal of this proprietary system is to measure and report on the academic achievement of UHS students enrolled in each one of our highly specialized programs and to provide each educational program a platform for continuous performance improvement. The UHS Best in Class platform consists of a set of national education standards, an annual school improvement plan (SIP) and outcome measurement tools. In addition to aligning with the UHS Best in Class program, many of our education programs are nationally accredited by Cognia or other state-approved accrediting organizations.

Grievance Reporting

The Committee raised concerns that staff and patients failed to report their concerns due to fear of retribution. UHS employees who want to report a problem or concern about inappropriate or unethical actions, not related to fraud, are encouraged to reach out to their supervisors, to management, to Facility Compliance Officers, the UHS Compliance Office or anonymously through using the Compliance Hotline or online platform.

Patients are also able to report their concerns via the UHS Compliance Hotline/platform. In addition, patients are able to submit complaints or grievances to their Patient Advocate – which is the way most patients report concerns.

CMS requires a very specific process to address patient grievances including how and when to follow-up with the patient after a review of the grievance itself. The requirements vary by state.  Nonetheless, our staff is trained and is compliant with the requirements relative to their respective facilities. Facilities’ Patient Advocate (and leadership, if needed) handles patients’ grievances in accordance with these CMS requirements.

UHS prohibits any form of retaliation against an anyone who reports, in good faith, acts of misconduct or wrongdoing. For employees, retaliating against someone for expressing a concern is subject to disciplinary action.

Conclusion

Let us first reiterate what we said at the top of this section, we acknowledge that there have been incidents over the years at some of our facilities where residents have suffered harm. Such incidents belie our commitment to provide a safe and therapeutic environment as well as the policies, procedures, protocols and training for our facilities. There is no place for any such incidents in our facilities and we are committed to ensuring such events are reduced with a goal of zero.

Notwithstanding, and as stated numerous times above, the Committee Report paints an inaccurate, incomplete and misguided picture of the quality of care and safety at UHS RTFs. The report also wholly fails to recognize the thousands of adolescents that have been successfully treated in our facilities over the years whose lives have been dramatically enhanced and quite possibly saved as a result of the care provided. The incidents and references cited in the report are not representative of the hard work of our dedicated staff whose only mission is to improve the lives of the residents they care for.

UHS remains committed to being a solution to ensure that the youth, who require this level of care in this country have safe and high-quality options that provide hope and recovery. This work is challenging and it is a high calling, one that each member of our UHS team takes very seriously. Our facility staff are dedicated to the mission of taking care of youth and work tirelessly to ensure that each resident is treated with dignity in a safe environment. Patients come to us after a broad variety of negative experiences – they need very specialized care and treatment. Incidents of staff failing to follow our training, policies, procedures and protocols are an extreme exception and not the norm. Patient and family success stories are our motivation. We have been providers for more than 40 years and we know that we are a valued resource in each individual community.

UHS stands ready to work with the Committee members and legislators and regulators at all levels to lend our expertise and experience in the industry to craft legislative proposals that enhance the efforts of RTFs and provide greater opportunities for care for the population that desperately needs this service.

[6] It should be noted that some of the items mentioned in the report relate to Acute Inpatient facilities and not a UHS RTF.  For example, the report cites to a recent verdict in Illinois involving The Pavilion Behavioral Health in Champaign, Illinois. That incident did not involve The Pavilion’s RTF but was at their acute inpatient facility.  Further, that case is currently subject to post-trial motions and the facility intends to appeal this verdict if those motions are not successful. We disagree with the jury’s verdict in that matter.

[7] As of the time of submitting this response, Benchmark Behavioral Health in Utah is currently under a Conditional License but is expected to be returned to full license standing by the end of June 2024. Benchmark has had three visits by their state agency in the last few months and there have been no identified concerns raised.

[8] The report incorrectly highlights one matter at Cedar Ridge where a staff member was alleged to be engaging in sexual activity with a resident, but the facility transferred the staff to another unit in lieu of termination.  This reference is incomplete and inaccurate.   The facts of this matter are more complex.  A staff member at Cedar Ridge initially thought there may be boundary issues involving the alleged staff member and reported that to facility management.  However, there were no allegations of inappropriate sexual contact between the staff member and resident, and no evidence to support such behavior at that time.  Notwithstanding, despite the lack of evidence present at that point in time, the facility transferred the employee to another unit pending a fuller investigation and re-trained and re-educated the employee regarding the facility policies on therapeutic boundaries. Subsequently, information became known to the facility that there may have been inappropriate sexual contact between the staff member and resident. At that point, Cedar Ridge immediately contacted the Oklahoma Health Care Authority who conducted an investigation which substantiated the allegations.  The facility then immediately terminated the employee and notified law enforcement.  This occurred over a course of 2 days.  The Committee Report completely failed to include the information that the employee was ultimately terminated even though we had advised them of that fact.

[9] The patient/resident risk rate is the percentage of patients that encounter this type of conduct or incident during a time period. If the resident risk rate is .003, that equates to .003% of all patients at UHS RTFs encountering this conduct. Conversely, 99.997% of the residents at UHS RTFs during this time period did not encounter or experience such an event. The same is true for other patient/resident risk rates referenced below.

[10] Some of these sexual encounters between staff and patients happened outside of the facility after the resident was discharged. Our incident tracking process does not separate the two as such contact and conduct violates our policies and procedures and the training our staff receive on boundary issues with residents (present and former).  However, the rate of sexual contact within the facility would be even lower if we were to only account for contact within the facility.

[11] The report references the number of times police were contacted from 2014-2019 by Provo Canyon School and Copper Hills Youth Center in Utah in response to an allegation of sexual assault. The fact that an allegation was made and police were contacted does not mean the event occurred. The majority of these allegations were unsubstantiated. Further, Provo Canyon School and Copper Hills Youth Center followed reporting rules by voluntarily contacting the appropriate agencies when an allegation is made – even if unsubstantiated, which includes law enforcement.

[12] UHS includes both consensual sexual activity as well as non-consensual activity in its data without distinction.  While consensual activity between residents is inappropriate and efforts are taken to prevent such conduct, the rate of non-consensual sexual activity would be even lower that the 0.027% rate referenced above if the data were segregated.

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