On an early March day in 2017, two teams of inspectors roamed Cascade Behavioral Hospital, probing how well the psychiatric facility complied with government regulations.
One team, sent by nonprofit The Joint Commission, determined the Tukwila hospital was in full compliance. The other team, from the Washington state Department of Health, found lapses so severe that inspectors declared a state of “immediate jeopardy” to patient safety. It was a jarring display of dissonance — and a common occurrence.
The Joint Commission, based in Oakbrook Terrace, Ill., is the largest of several private-sector organizations that vet the quality of health-care providers on behalf of the federal government — and the only one authorized to inspect psychiatric hospitals. The month before the Cascade inspection, the commission had been removed from a yearlong period of review and probation by federal authorities for missing serious safety violations. But in Washington state and beyond, government inspectors continue to find serious problems at psychiatric hospitals accredited by the commission, a review by The Seattle Times found.
The Joint Commission, which publishes accreditation data online, provides one of the only public signals of a hospital’s quality. Its quasi-governmental authority gives it great power: Of the psychiatric hospitals that receive reimbursements from Medicare, 85% owe their eligibility to the commission. Hospitals, with the commission’s encouragement, use its trademarked “Gold Seal of Approval” to promote their services. Regulators consider accreditation in evaluating hospitals’ compliance record.
Dr. Mark Chassin, the commission’s chief executive, said its surveyors are trained “not to be ruthless, punitive inspectors,” according to a Q&A published on its website in December 2017. “What does it take to deny accreditation?” Chassin said in the document. He answered: “being unable or unwilling to improve.”
In response to questions from The Times, a spokeswoman for The Joint Commission said, “Hospitals where violations are identified do not automatically lose their accreditation,” adding that “The Joint Commission and CMS [Centers for Medicare and Medicaid Services] allow hospitals time to development improvements and regain compliance.”
Government scrutiny of the accreditation firm stretches back to at least 2014, according to documents reviewed by The Times.
That fall, Joint Commission staffers evaluating Springfield Hospital Center in Maryland found that “medical records were being falsified in order to satisfy an internal chart review,” but they were not concerned. “All facilities do this,” a commission field director told hospital staff, according to federal records of the inspection reviewed by The Times.
Observing this exchange were representatives of CMS, who were evaluating the commission’s work, and they took exception to it. If all commission-accredited facilities “falsify medical records in this manner,” a senior CMS official wrote in a letter, it suggests that the firm has condoned “a practice that not only violates Medicare standards but which is also potentially dangerous for patients.”
CMS officials were concerned about more than what they called the “cavalier attitude” of commission staff. They compared a sample of inspections by the commission and state regulators who toured the same psychiatric hospital around the same time. Over a four-year period, The Joint Commission inspectors missed serious violations flagged by government inspectors in 70 percent of the cases, the agency found.
The Wall Street Journal reported last December that more than 100 psychiatric hospitals had remained accredited by the Joint Commission despite being cited for serious violations by state officials in 2014 and 2015.
By 2016, the commission had shown improvement, according to CMS. In a sample of 21 psychiatric hospital surveys, it missed serious violations found by state inspectors only 57 percent of the time. The sample represented 11 percent of the commission’s accreditation inspections that year.
In its response to The Times, The Joint Commission said it “takes falsification of records very seriously” and has “denied accreditation to organizations where there is evidence of the falsification of records.” The spokeswoman added, “We are not aware of any accurate data which would indicate that state agencies find serious violations significantly more often than The Joint Commission.”
CMS said it has strengthened oversight of accreditation organizations like The Joint Commission, such as a pilot program that sends agency staff to shadow the organizations’ inspectors during live surveys.
When government regulators find that a Joint Commission-accredited hospital has failed to meet federal standards, the hospital is placed under state jurisdiction until it has demonstrated compliance. The commission issued a “preliminary denial of accreditation” to Cascade in February 2017 but granted full accredited status the following month, according to its website.
Washington state inspectors declared an immediate jeopardy to patient safety at Cascade three times from December 2016 to May 2017, and have cited deficiencies at least six times since then.
Michael Uradnik, Cascade’s chief executive, said the “overwhelming majority of survey inspections” — including state, federal and by The Joint Commission — “resulted in definitive determinations that our hospital was in substantial compliance” with regulations.
Last year, regulators found serious violations at three Joint Commission-accredited psychiatric hospitals in Washington state: Navos, in West Seattle; BHC Fairfax Hospital, in Kirkland; and Smokey Point Behavioral Hospital, in Snohomish County.
Despite scrutiny of The Joint Commission, the Washington state Department of Health has continued to give some weight to its accreditation decisions in reviewing the compliance record of health-care firms that apply to open or expand in the state. The state regulator cited commission accreditation as support for approving or expanding seven new psychiatric hospitals since 2014. State officials said the accreditation was “one data point” among many.
When a new company called US HealthVest applied to build multiple psychiatric hospitals in Washington, the department reviewed The Joint Commission’s website for data on a predecessor, Ascend Health, run by the same executive team.
Ascend’s hospitals, in the Joint Commission reports, “were considered comparable to the national patient safety and quality improvement goals,” the department concluded. A Department of Health spokeswoman said agency staff made inquiries with regulators in states where Ascend operated but didn’t learn of any concerns. Had the regulator checked with CMS, it would have discovered that at least two Ascend hospitals were cited for serious violations in the year before the company was acquired by Universal Health Services.
Since US HealthVest opened its first hospital in Washington, Smokey Point Behavioral Hospital, in the summer of 2017, government inspectors have found violations of state and federal standards on 12 separate visits. Based largely on this record, the department denied the company’s application to build a third psychiatric hospital.
“Smokey Point has been and continues to be, fully compliant with all state and federal regulations,” Richard Kresch, US HealthVest’s chief executive, said in a statement. The hospital has never lost its Joint Commission accreditation.