The Oregon Health Authority conducted a broad review of Clatsop Behavioral Healthcare after the wrongful arrest of a patient at the crisis respite center, identifying concerns over how the agency’s executive director was placed on administrative leave and whether clinical documentation improved after a state visit last year.

The health authority determined a review of the agency’s mental health and substance abuse treatment was necessary after what the state described as “a serious incident” at the respite center in Warrenton in December.

Clatsop Behavioral Healthcare

Video footage of a fight between two patients one evening showed the wrong patient was arrested by Warrenton police. The error was discovered within a few hours, but detonated a leadership clash that exposed several other management and oversight problems.

Debbie Morrow, the board chairwoman, placed Amy Baker, the executive director, on administrative leave in late December pending an internal investigation of Baker’s on-call responsibilities at the respite center. The board cleared Baker after the investigation, and she returned to work in January, but Morrow and another board member resigned in protest.

The health authority, in its review, received reports that Morrow handled Baker’s leave in “an unprofessional manner, traumatizing Clatsop Behavioral Healthcare employees.” The reports claim Morrow acted unilaterally and did not notify the agency’s executive management team about Baker’s leave or the appointment of an interim director.

The state found that the board’s bylaws do not address succession planning for any purpose or reason. In response, Baker said the board assigned a policy committee to draft language for bylaw amendments on succession planning, the board acting as a unified voice and a staff communication plan. The board also had a four-hour training session on board roles and responsibilities.

Morrow could not be reached for comment. She said after she resigned in January that the board and the agency no longer aligned with her core values.

Crisis respite center

The Oregon Health Authority did a separate review of the crisis respite center after Monica Steele, the interim county manager, notified the state about the wrongful arrest. The state’s findings, which were critical, were released in late January to Baker and shared with the county.

Baker, however, has asked the health authority to consider making corrections to the findings once a report by the state Office of Training, Investigations and Safety is completed. The agency, known as OTIS, investigates allegations of abuse, and Baker believes the role of the respite center staff in the wrongful arrest will be clarified.

Clatsop Behavioral Healthcare has sought to improve operations at the respite center. Experts from Cascadia Behavioral Healthcare, which serves the state’s largest metro areas, visited in January to make recommendations on staffing, programming and training.

But any changes will happen under new leadership.

Jennie Chrisenbery, the program manager at the respite center, resigned in February, along with another top manager.

“They have worked tirelessly with their staff to serve our residents and the pace of running a 24/7 program can be unrelenting,” Baker said in an email. “They have both resigned for personal reasons and they will both always be welcomed back here at CBH.”

Steele said Clatsop Behavioral Healthcare is responding to the state’s concerns. The county contracts with the private nonprofit for behavioral health and developmental disabilities. The contracts, which expire at the end of June, are up for bid.

“I would like to say that while it is unfortunate that there was an incident that occurred at (the respite center) that prompted much of this media attention, CBH staff are actively working on addressing the concerns brought forward by the state, as well as acting on recommendations that have been made when Cascadia came and did an assessment at the request of CBH administration,” Steele said in an email.

“It is also unfortunate, as pointed out in the OHA report of the overall CBH mental health services, that the handling of this incident by the former chair that has resulted in undue stress for the staff.”

State questions

The Oregon Health Authority’s overall review of mental health and substance abuse treatment, which was conducted in late January and released in early February, identified more than a dozen issues and required Clatsop Behavioral Healthcare to submit a plan of correction.

The agency needed to improve policies on patient grievances and appeals, individual rights, quality assessment and performance, and clinical supervision of program staff, the state found.

In one finding, a mental health service record for a suicidal adolescent did not include a safety plan. The state requires a safety plan when a patient’s assessment indicates they pose a risk to the health and safety of themselves or others.

In another finding, medical protocols for people in outpatient substance abuse treatment did not designate the medical symptoms that would require further investigation or specify steps for follow-up with primary care services. The state also questioned whether the agency has a medical director.

Baker said in an email that the agency is working with Iris Telehealth, a telepsychiatry company, to provide a medical director. The former medical director, she said, still provides consultation to staff on high-risk patients.

Several of the health authority’s findings were also identified by the state in a recertification review of Clatsop Behavioral Healthcare issued in February 2018. State compliance specialists, who attended the earlier review, reported that the “clinical documentation did not appear to have improved.”

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