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Concerns and questions surround 'surprise' state inspections at Colorado mental health facility

Insiders say leaders at Johnstown Heights Behavioral Health are tipped off before state inspections
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Posted at 9:55 PM, Jul 10, 2023
and last updated 2023-07-11 14:26:13-04

JOHNSTOWN Colo. — The credibility and integrity of state inspections are being brought into question following testimony from former staff and patients at a Colorado mental health facility north of Denver, who claim the state announces their inspections prior to showing up.

One former mental health technician at Johnstown Heights Behavioral Health says regulators at the state level are overlooking serious safety concerns inside the 92-bed facility. His distress centers around what he witnessed inside the hospital, after being assaulted twice.

“I believe it's not a safe place for patients or staff,” he said. “I was assaulted twice ... the second time I was assaulted I was sent to the hospital.”

The former mental health technician tells Denver7 Investigates staffing was low on the day of his assault. He now questions the performance of state regulators, paid by tax-payers, to make sure mental health facilities are secure, safe, and properly staffed.

He says Johnstown Heights is given days to prepare for what should be surprise inspections, per state code.

“I feel like if it had been a surprise there would have been a lot more issues they found within the facility, “ he said.

Other former staff and patients share the same concerns, telling Denver7 Investigates, the state’s oversight is being overlooked.

“Whenever they had state come in they would staff up,” one former nurse said. “They would call people in and say, 'It's all hands on deck. Everybody's got to be here.' So it appeared to the state that we were fully staffed.”

Another former employee says because of the preannounced inspections, senior leaders at Johnstown Heights had the opportunity to muffle the message to the state.

“I know the state has gone in plenty of times to talk to people, but nobody can actually say the truth because somebody is always hovering. Someone is always listening,” she said.

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A former patient tells Denver7 Investigates, she didn’t receive the help she needed at Johnstown Heights, calling the facility unsafe. She says state regulators need to take a closer look.

“I think they definitely need to take a closer look and dig a little deeper,” she said. “With a place like this, with as many complaints as they have had and the issues that they're showing, they should not announce visits. They should be popping in randomly.”

However, state regulation lays out inspection best practices, highlighting, "The licensee shall provide accurate and truthful information to the Department during inspections, investigations, and licensing activities."

“I feel if it had been a surprise there would have been a lot more issues they found within the facility,” the former mental health technician said. “Because when you have the time to prepare for something like that you are going to cover your tracks and they're not going to find what is really going on there.”

November 2022, Christopher Dickson died in the detox unit at Johnstown Heights. A state inspection nine days after his death found at least ten deficiencies, and declared the hospital in “immediate jeopardy.” Immediate Jeopardy is the state’s most serious designation for a mental health hospital.

One portion of the state’s November report noted the lack of attention to Dickson, despite his condition at times requiring hourly checks. He had not been checked for eight hours before his death, according to the report.

“I'm not surprised they found everything I thought they'd find… inadequate staffing, inadequate safety measures,” said BJ Potts, a veteran nurse who resigned from Johnstown Heights two weeks before Dickson’s death after being assaulted by patients.

Concerns and questions surround 'surprise' state inspections at Colorado mental health facility

Since Johnstown Heights opened in 2021, state records show 29 inspections producing 28 citations. But employees and patients say by announcing visits, state inspectors are not seeing the true picture.

“I hope that [state regulators] rethink how they run things and that they are more thorough and pay more attention to the things they seem to overlook,” the former mental health technician said.

“Stop this from happening to anybody else. Nobody else should lose their life being there. Nobody should feel less than a human being held there,” the former patient said.

A second immediate jeopardy was declared at the hospital in April. The most recent report by the state cites the facility's failure to keep patients safe.

The inspection details an incident where multiple employees, including senior-level managers, carried a patient out of the facility by her arms and legs and dumped her into the parking lot. That patient was being treated because of suicide threats.

Elaine McManis is the director of facilities inside the Colorado Department of Public Health and Environment, the state agency responsible for inspections. She declined an on-camera, in-person interview with Denver7 Investigates. Instead, the state responded via email, pointing to current procedures which state they regularly conduct unannounced inspections.

"We recognize that unannounced investigations are the best way to truly understand the care that is provided at a facility and do not inform facilities of investigations before they begin under our state jurisdiction," the state wrote.

Johnstown Heights CEO Sean Peterson did not return multiple phone calls seeking comment.

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Clear View Investigation

1:02 PM, Jun 18, 2019

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